Second Time Trying
Our first child -- one of those babies jokingly referred to as an "accident" -- was not quite 2 when my husband and I decided we wanted another. At the time, it didn't seem arrogant to think of this as a decision and not merely a hope. After all, if I could conceive without meaning to, how hard could it be to get pregnant on purpose? We'd just grin at each other one afternoon during the baby's nap, and a few weeks later a little blue line would magically appear in the window of a pregnancy test.
Two years and two miscarriages later, we had learned a sad lesson in human biology: Fertility is not always within our control.
Like many couples who easily conceived and carried their first child, we faced a shocking diagnosis: secondary infertility. Medically, the term refers to parents who, after 12 months of unprotected intercourse, have failed to conceive another child, but most experts also include recurrent miscarriage in the definition. And in human terms, the result is the same: a blank space in a family where a child is longed for.
Indeed, one of the best-kept secrets of the fertility industry is that nearly a quarter of couples seeking treatment are already parents. Some of these patients had trouble conceiving the first time, so they know what they're up against when they try again. But many others, like my husband and me, have been stunned to learn that, "in fertility, past success is no guarantee of future success," as Michael DiMattina, M.D., director of Dominion Fertility and Endocrinology, in Arlington, Virginia, puts it.
Yet, according to Dr. DiMattina, people suffering secondary infertility are only half as likely to seek treatment as those facing primary infertility. Partly, Dr. DiMattina says, this reluctance stems from emotional denial. "Previously fertile people tend to think, If I just give up coffee or reduce my stress, it will happen." Though such measures undoubtedly enhance general health, he says, "they won't cure infertility." To complicate matters, busy ob-gyns often assume there's no medical reason when patients who have previously demonstrated their fertility take an unusually long time to conceive. Unfortunately, such a wait-and-see approach can allow an untreated problem to become an untreatable one.
What Causes Secondary Infertility?
The decline in fertility between a first and a hoped-for second pregnancy can often be chalked up to age. A woman's most fertile years are between ages 15 and 30, with a drop-off occurring at 30 and a quite precipitous plunge at 35. (In fact, by 36, almost 25 percent of women may already be infertile.) Many women are unaware of this reality and delay first-time pregnancy until 30 or beyond. That means they are even older when seeking a second. It is thought that a woman's eggs suffer chromosomal damage as they age; the older the eggs, the more damaged they are, and the less likely they are to become fertilized or go to term.
Passing time also means that other conditions, not specifically age-related, can develop where they didn't previously exist. Hormonal shifts or other endocrine problems can crop up, altering the body's delicate balance. And endometriosis, an ailment in which the uterine lining attaches itself to other pelvic organs, worsens over time if left untreated, creating tubal blockages that prevent conception or cause ectopic pregnancies. (The latter occur when the fertilized egg implants itself somewhere other than the uterus -- usually in the fallopian tube, which may rupture and need to be surgically removed).
Male-factor causes -- low sperm count or poor sperm motility -- are the culprit in about 40 percent of infertility cases. Occasionally, the change in a man's fertility can be traced to a chronic illness such as hypertension or diabetes, explains Esther Eisenberg, M.D., director of the Reproductive Endocrinology and Infertility Center at Vanderbilt University Medical Center, in Nashville. Excessive alcohol consumption or moderate marijuana use can also impair male fertility.
More often, though, the reason for the change simply can't be pinpointed, making the diagnosis especially bewildering. "We had a child, so we expected the test to come back fine," says Tara Jenkins, 23, from Mitchell, Indiana, who took a year to conceive her 3-year-old daughter. "It was a real blow to find out that my husband had a low sperm count."
Hidden scars are another possible cause. Untreated infections (after a D&C, for example, or childbirth) can leave abnormal tissue in the uterus. These adhesions may prevent a fertilized egg from implanting properly or create scarring in the fallopian tubes, which keeps an egg from reaching the uterus. A new mother may develop an infection without realizing it, Dr. Eisenberg says. A woman who's never had a baby before can be completely unaware of how much postpartum pain or bleeding is normal, and many women have symptoms of infection they never report. Their diminished fertility won't be discovered until they try to conceive again.
Sandy Mott, 36, of Sterling, Virginia, easily became pregnant in 1991 and 1993 and seemed to sail through both deliveries. Mott's doctors now believe, however, that she suffered an undiagnosed infection following the birth of her second son. The resulting scars contributed to an ectopic pregnancy in 1998 that went undiagnosed until it ruptured a fallopian tube; a second ectopic pregnancy was caught early and removed. Because of scar tissue in her one remaining tube, an expensive in vitro fertilization (IVF) procedure was Mott's best option. After one failed IVF attempt, Mott and her husband were ready to call it quits but decided to try again when they got new health insurance with some infertility coverage. This time, the procedure worked, and the couple's third son was born last June.
But the most common diagnosis by far -- in as many as 20 percent of all cases -- is simply "unexplained infertility." In other words, says clinical psychotherapist Harriet Fishman Simons, Ph.D., author of Wanting Another Child, Coping With Secondary Infertility (Jossey-Bass), "there's no diagnosis at all. It's not clear whether some factor has been in existence all along and the couple was just lucky or whether the factor has become exacerbated over time." Because it is so vague, the "no known cause" verdict can be particularly hard to accept: "After all, these parents have living proof of their fertility," Dr. Simons says.
"Our two older children were conceived with barely a thought," says Ellen Rosenblum, 37, of Aurora, Colorado. "How were we to know that the third time would be so different?" After trying to conceive for eight months, she and her husband underwent fertility testing, without clear results. Although the couple eventually had a third child, now 6 months old, "it was incredibly frustrating," Rosenblum says. "When there's a diagnosis, at least there may be a treatment plan."
How Long Should You Wait?
The amount of time you should allow before consulting a fertility expert operates on a sliding scale according to age. (Remember: Even at the peak of fertility, a woman's chances of conceiving during any given cycle are about 30 percent.) If you are under 30, give it 12 months; if you are over 30, you should try for 6 months.
Many ob-gyns have attended infertility workshops and are competent to perform basic diagnostic procedures and to prescribe ovulatory medication, but they have received only a fraction of the training of a board-certified reproductive endocrinologist. If you've had no success after six to nine months of treatment, see a specialist. (If you need help locating a board-certified reproductive endocrinologist in your area, log on to the Website of the American Society of Reproductive Medicine, at www.asrm.org).
The good news: Secondary infertility is more likely to be treatable than primary infertility. If you act promptly, consult with a specialist, and faithfully follow the prescribed treatment plan, you have every reason to feel confident that eventually you'll have another baby.
The Infertility Roller Coaster
As hard as it may be to believe, studies show that the emotional effects of secondary infertility are identical to those of primary infertility. According to Parents adviser Alice Domar, Ph.D., director of the Center for Women's Health at Harvard Medical School's Mind/Body Medical Institute and coauthor of Six Steps to Increased Fertility (Simon & Schuster), "Women being treated for secondary infertility are just as depressed and anxious as women who don't have a biological child." Moreover, secondary-infertility patients must cope with emotional issues not faced by childless patients. Here are a few of them.
"Secondary-infertility patients are in a kind of no-man's land," Dr. Domar points out. As parents, they're shunned by the infertility world, which is apt to see them as ingrates because they already have a child. Yet they feel alienated from the fertile world because they cannot conceive. And though childless couples can immerse themselves in adult concerns, focusing on travel or career, parents of small children encounter pregnant women and newborn babies everywhere they go. Indeed, some of the best supports they've experienced as parents -- mother-and-child playgroups, for example -- can become, says Dr. Domar, "the greatest source of hurt, because these parents no longer feel like part of the club."
Jealousy and Resentment
Normally rational people often find it difficult to think clearly about infertility; the pain and frustration simply overwhelm logic. "I couldn't quite grasp the fact that other women's pregnancies didn't hurt my chances in any way," admits Sandy Mott. "Somehow I felt that there were a limited number of babies out there, and if I didn't get pregnant soon, there wouldn't be one for me."
"It feels like a knife in my heart whenever someone tells me she got pregnant by accident," agrees Carolyn Hutton, 29, of Campbell River, British Columbia, who is facing infertility for the second time, after having successfully given birth to a son six years ago.
"A lot of patients feel guilty because they're given the message that they should be grateful for the child they have," Dr. Simons says. "They are grateful, but that doesn't take away the longing for another child." "This desire is just as urgent, just as desperate and all-consuming as it was the first time around," says Anne Clements*, an East Rutherford, New Jersey, mother who easily conceived her 3-year-old daughter but has miscarried two subsequent pregnancies. "Sometimes I feel greedy for wanting another miracle so badly."
Some patients feel nothing but fury when others fail so utterly to understand the way they feel. "I am so sick of people telling me to be thankful for Samantha," says Valencia, California, mother Melinda Gruman, 27, of her daughter, now 2. "As if I'm not?"
Melissa Swanson, a Reno, Nevada, mother who prematurely delivered triplets, who did not survive, before successfully giving birth to daughter Amanda, now 5, says, "Of course I'm grateful to have one healthy child: I went through hell and buried three babies to get her. But does that fulfill me? No. I never imagined raising an only child." Being told to feel grateful, Swanson says, is also unfair. "No one says to a woman expecting No. 2, 'Gee, why are you pregnant again? Aren't you grateful for little Bobby?'"
Pressures From the Baby
Sometimes little Bobby himself innocently adds to the heartache. Two weeks after my second miscarriage, my 3-year-old son was with me in a store changing room; when I asked what he was saying to himself in front of the mirror, he answered, "I'm pretending I have brothers." Confused, he patted my shoulder over and over as I held him in that cold little cubicle and cried.
"One of the most poignant experiences for secondary-infertility patients is when their child begins to ask for siblings," Dr. Simons agrees. "They feel they're letting her down." Peggy Birck, of Bethpage, New York, says, "My daughter, Lauren, asks for a sister every day, and it breaks my heart. I know she would be a great big sister."
Existing children can also complicate treatment. Couples who are already parents may find it hard to justify the high costs, which often run into tens of thousands of dollars and are rarely covered by insurance.
There's also the issue of child care. "Infertility treatment is very demanding," Dr. Domar explains. "A lot of treatments require daily blood tests and ultrasounds, injections, and other procedures, and it's hard to do all that when you have a child."
Like primary infertility, the secondary variety can take a steep toll on a relationship. But according to Dr. Simons, couples suffering secondary infertility are more likely to be out of sync than childless couples (though most survive the stress). Tara Jenkins, whose infertility derives from both ovulatory problems on her part and low sperm count on her husband's, says, "It's a good thing he's so tolerant, because the drugs turn me into a real monster."
Many times, too, mothers want to pursue treatment, while fathers argue for settling for the family they've got. "These treatments can be very disruptive, and a lot of men want their happy family back more than they want to add to it," Dr. Simons says.
"My husband is having a harder time dealing with me than with the miscarriages," admits Anne Clements, voicing a common theme. "His biggest complaint is that I am obsessed."
Copyright © 2001 Margaret Renkl. Reprinted with permission from the February 2001 issue of Parents magazine.
All content here, including advice from doctors and other health professionals, should be considered as opinion only. Always seek the direct advice of your own doctor in connection with any questions or issues you may have regarding your own health or the health of others.