What Is Secondary Infertility?

No one wants to struggle with infertility, regardless of its origins. But if you’ve conceived in the past with no apparent difficulty, infertility can be particularly shocking.

What is secondary infertility?

Secondary infertility is when an individual or a couple has difficulty conceiving or carrying a pregnancy to term, despite having prior biological children with no difficulty.

About ten percent of couples who had no trouble conceiving previously will experience secondary infertility. Though it has many of the same causes as primary infertility, this topic doesn’t seem to receive as much attention in the media or in society.

Unfortunately, many couples struggling with secondary infertility find themselves suffering in silence. Well-meaning family and friends try to convince them that they should be content with the family they already have. Coworkers remind them that they already have one or more children and should just focus on that. Your Great Aunt Sue reminds you to “just relax, and it will happen when you least expect it!”

Sadly, there are even medical providers that fail to take your concerns seriously, not giving your case the attention it deserves simply because you have successfully conceived a child before.

But regardless of whether the desired pregnancy is the first child or the sixth, no one should be shamed by others for their desire to grow their family.

What causes secondary infertility?

There are multiple possible causes of secondary infertility. Many of them are the same factors that cause primary infertility. Unexplained infertility is also a common diagnosis. These difficulties in conception can occur at any point in the early pregnancy process: ovulation, sperm production and travel, fertilization, travel of the fertilized egg, or implantation in the uterus. These problems can originate with either a male or a female partner. Though it would be rare for both partners to have developed problems in the time since the conception of the prior child, this is also a possibility.

Here are a few possible causes of secondary infertility, though of course you’ll need to work with your healthcare provider to determine what specific factors are at play in your case.

  • Change in sperm quality and quantity. As a man ages or changes his lifestyle, the quality and number of sperm in each ejaculation can decline. This can be linked to smoking, alcohol intake,  changing testosterone levels and environmental exposures. Sperm morphology and motility can be checked through a semen analysis.
  • Endometriosis. Endometriosis happens when tissue similar to the uterine lining (“endometrium”) grows outside of the uterus, in places like the ovaries or fallopian tubes. This lining can cause scarring in the pelvis and on the fallopian tubes, making it impossible for the sperm to reach the egg or for a fertilized egg to pass through the fallopian tube to the uterus.
  • Uterine fibroids. Fibroids are noncancerous tumors found in the uterus. Some uterine fibroids occur in the uterine cavity and can make implantation difficult.
  • New medical problems. If you have been diagnosed with a new medical condition since your last pregnancy, this could contribute to secondary infertility. Polycystic ovary syndrome, diabetes, autoimmune concerns, uterine polyps, and pelvic inflammatory disorder are examples of conditions that may make conception more difficult than it has been in the past.
  • New medications. Likewise, if you are taking new prescription or over-the-counter drugs, this may affect fertility. Drugs taken for epilepsy, thyroid, pain medications, some steroids, and chemotherapy have been known to impact fertility.
  • Complications from prior pregnancy. Any uterine scarring can cause difficulty with the implantation process. Talk to your physician about your particular prior pregnancy and birth experiences to see if this could be a factor.
  • Complications from prior surgeries. Complications from prior surgeries can lead to scar tissue in the uterus or pelvis that can impact fertility.
  • Age. It goes without saying that both partners are more advanced in age than they were when the prior pregnancies were conceived. Because female fertility tends to decline in the mid-30s, the more a woman ages, the lower her egg quality tends to be.
  • Lifestyle factors. Habits frequently change after one becomes a parent. There are a few lifestyle factors that can possibly contribute to infertility. It’s harder to round up your child and the stroller and get out the door for a walk than it was when you just had to grab your keys and go. Maybe you’ve returned to a smoking habit you picked up in college. Perhaps you find yourself reaching for the wine bottle more often than you did before. It’s easy to slip back into these methods of coping in the busy years of raising small children. Focusing on eating whole, nutritious foods, moving your body more, stopping smoking, and cutting back on heavy alcohol consumption can contribute to a healthy lifestyle that can support fertility.

What is the treatment for secondary infertility?

Just as the causes of secondary infertility are similar to primary infertility, the treatments can be similar as well. After performing a thorough examination and history, your provider can order lab tests to check your hormone levels. A semen analysis is also commonly ordered to check the number and motility of viable sperm.

There are a number of treatments that can be helpful for secondary infertility. These can include medications such as Clomid or letrozole. Intrauterine insemination (IUI) or IVF may be considered as well.

When should I get help for secondary infertility?

If you’ve been having unprotected sex for more than a year, consider seeking medical help. If you are over the age of 35, this time period can be shortened to six months. And if you are over the age of 40 or you have been experiencing irregular menstrual cycles, contact a fertility specialist right away to get the help you need.

Secondary infertility can be a very unwelcome surprise, but The Integrative Fertility M.D. is here for you. Reach out – we’d love to help you with your family planning goals!

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10 Common Fertility Tests Explained

As if infertility isn’t overwhelming enough on its own, keeping track of fertility testing names, schedules, and results can leave you completely befuddled.

“Which tests? Are these blood tests or ultrasounds? This dye goes where, now?”

And how do you keep track of which blood draws need to take place on which days of your menstrual cycle?

We’re here to demystify this process for you!

Why would I need all these tests?

The results of these labs can help your provider determine the reasons that you’ve been struggling to conceive or maintain a pregnancy. And if you’re considering growing your family with fertility treatments, the results can also help determine what your next steps will be.

Important fertility tests

Here are 10 of the most common tests your provider may order when trying to assess the reasons behind your infertility.

  • Anti-mullerian hormone (AMH) level. AMH level is assessed through a blood draw, and it evaluates ovarian function. A low AMH level can indicate a low egg count, which could be the cause of your fertility struggles. But this isn’t always the case! AMH might be most useful in helping your doctor predict how you might respond to certain fertility medications.
  • Prolactin level. Prolactin is a hormone made in the pituitary gland in the brain. It’s the hormone that’s primarily responsible for breast milk production after birth. But unusually high levels of prolactin can be linked with infertility and irregular or absent periods as well, so this level can help pinpoint if that might be causing your difficulties conceiving. A normal prolactin level in a female who is neither pregnant nor lactating is less than 25 ng/mL.
  • Day 3 follicle-stimulating hormone (FSH) level. As its name indicates, FSH stimulates the ovarian follicle to be produced. FSH is the primary hormone responsible for selecting which follicle will be released. This follicle production then proceeds to ovulation. By testing this level very early in the menstrual cycle, your provider can get an idea of how hard the body is trying to stimulate follicle production. Simply put, an elevated FSH level can indicate that the body is having to do extra work to produce a follicle. FSH levels typically increase with age.
  • Day 3 estradiol level. This level is closely related to FSH, so it’s typically drawn along with the FSH test discussed above. If estradiol is elevated but FSH is normal, this can signal problems with the response of the ovary. Estradiol level less than 80 is considered normal at this point in the menstrual cycle.
  • Progesterone level. Progesterone is a hormone that rises in response to ovulation. A rising progesterone level can help confirm that ovulation is occurring, so this test is timed for about a week after suspected ovulation. Your progesterone levels will need to be interpreted by your care provider, of course, but low levels may suggest that ovulation didn’t occur or that post-ovulatory progesterone levels may be too low to sustain a pregnancy.
  • Hysterosalpingogram (HSG). Whereas a lot of these other tests look at your hormone levels, the HSG evaluates the patency (openness) of your fallopian tubes. The physician performing the HSG will pass a very small catheter through the opening of your cervix and insert dye into the uterus. After inserting the dye, a pelvic x-ray is taken. If the uterus fills abnormally, there might be a polyp, fibroid, or malformation of the uterus. If both fallopian tubes are unblocked, the dye will spill out through the fallopian tubes. If there are any blockages in the tubes, the dye will stop at the blockage.
  • Antral follicle count (AFC). This count is performed by vaginal ultrasound. Egg count and quality decrease as women age, and this test evaluates ovarian reserve. Your antral follicle count can give your provider an idea of where your fertility ranks in relation to your age. Because egg count decreases as you age, this number will be lower the closer you come to menopause.
  • Thyroid testing. Hypothyroidism (low levels of thyroid hormones) can prevent the release of the mature egg from the ovary, leading to difficulty conceiving. There are several blood tests that can help evaluate thyroid function, but one of the most common is thyroid-stimulating hormone (commonly referred to as TSH). Healthy levels of TSH can vary based on your specific case.
  • Diabetes testing. Fasting blood sugar levels can help determine if further testing for diabetes is warranted since diabetes can be associated with infertility.
  • Semen analysis. All of the tests above have been primarily performed on the female partner, but semen analysis is vital to the fertility treatment process! This is because male factor infertility can be the cause of up to half of cases of infertility. Semen analysis is normally one of the first fertility tests performed, as it is less invasive than others. Semen analysis is most accurate when it follows 24 to 72 hours of abstinence. It’s also important that the sample be examined within an hour after collection. The semen is examined under a microscope and the number, shape, and movement of the sperm are observed.

You might not need all these tests!

Though these tests are important, every case is different! Not every test on this list will be required before starting treatment for each patient. It’s vital that you discuss the specifics of your situation with a fertility specialist to understand which could benefit you!

Fertility treatments can be confusing, and it’s easy to become overwhelmed with the testing process. We understand the overwhelm and are here to walk you through the process! We also know that you may still have questions about some of these tests.

Regardless of the specifics of your fertility case, we consider it an honor to accompany you on your journey. Contact us today to consult with Dr. Salem about which of these tests would be best for you!

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What is the Uterine Microbiome?

Researchers estimate that the human body contains approximately seven quadrillion bacterial cells! Most of us hadn’t even heard the word “microbiome” until just a few years ago. But now the concept of gut health and gut flora are all over the news! It seems like every week a new connection is made between gut health and some other facet of wellness.

Research has recently shown that the balance of bacteria in our guts affects not only our gastrointestinal systems, but our hearts, kidneys, and even our brains and mental health! The microbiota of the skin has gotten some media attention as well.

The uterine microbiome, though, hasn’t received as much press time as it deserves! In fact, until quite recently scientists believed that the uterine environment was sterile (meaning there were no microorganisms present in it at all.)

Flora and microbiome and endometrium, oh my!

Let’s start by defining some of these words! Just as you’ve likely heard the plant life in a certain area referred to as the area’s flora and fauna, the term “flora” simply refers to the normal, beneficial bacteria that resides in or on the human body. “Microbiome” is just another way of referring to this healthy bacteria.

In this article, we’ll be discussing the unique microbiome of the uterus, which is contained in the endometrium. The endometrium is the lining of the uterus. This is the cushioning where a fertilized egg implants at the beginning of a pregnancy. In a normal menstrual cycle, the endometrium becomes thicker after ovulation in order to prepare for a potential pregnancy. It is then shed during menstruation if no pregnancy occurs.

Learning more about the unique microbiome of the uterus

Advances in modern medicine have allowed physicians to study the endometrium’s microbial environment with more precision than ever before. Early studies suggest that the most common bacterium in the uterus are called Bacteroides and Lactobacillus.

One study compared samples from the endometrium and vaginas of 35 infertile women undergoing in-vitro fertilization treatment. The results of this study revealed an important discovery: the women with more non-Lactobacillus bacteria in their microbiomes had decreased likelihood of implantation, pregnancy, and live birth.

Currently there are limited studies about the impact of the endometrial microbiome on fertility levels and success with IUI, IVF, and other fertility treatments. However, testing has recently become available to assess the endometrial lining for various types of bacterial flora. Hopefully this will open doors in the future for the ability to treat a uterine microbiome that is not ideal for conception.

Where does this beneficial bacteria come from?

Currently the most common theory is that the flora that populate the uterus ascend from the vaginal canal. The vagina has its own microbiome, and it can fluctuate frequently. Immediately prior to ovulation, for example, Lactobacillus levels tend to stabilize, then these levels drop during menstruation.

But are there other external and lifestyle factors that affect the balance of bacteria in the vagina (and thus the uterus)? Studies suggest that this may be the case! Menstruation, sexual activity, and use of period products like pads, tampons, and menstrual cups. There is also some evidence that the use of a copper IUD can increase an imbalance in the vaginal flora. Some other studies, however, suggest that the flora of the vagina are only affected by ethnicity and number of sexual partners. Clearly there is much we have yet to learn on this subject!

Another microbiome?

No discussion of bacteria’s influence on reproduction would be complete without a brief mention of yet another microbiome: the placental microbiome. After a pregnancy is achieved, any elements that interfere with the communication between the embryo and the uterine lining can interfere with the pregnancy. An imbalance in the uterine or placental microbiome, then, might set off an inflammatory response that can be possibly linked to a poor outcome and loss of the pregnancy.

You might be aware that the immune system becomes slightly suppressed during pregnancy in order to protect the developing embryo. This happens so that a woman’s body doesn’t recognize the developing embryo as an intruder and thus attacks it as a foreign object. If there is a severe imbalance in the flora of the uterus and placenta, then, it makes sense that the body would attempt to eliminate this.  However, this attempt to exterminate the flora imbalance could lead to devastating consequences for a pregnancy.

You don’t have to struggle alone

These issues can be isolating and confusing, but we are committed to walking this journey alongside you and explaining all the nuances. Testing is now available to evaluate your uterine microbiome. Speak with your fertility doctor to see if you are a candidate for this testing based on your case!

To connect with Dr. Salem and her team, contact us today to arrange a consultation!

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