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What is Secondary Infertility?

A blog by Dr. Matthew A. Lederman, RMA of New York, March 9, 2015

Secondary infertility refers to couples who have had a successful pregnancy in the past, but then experience difficulty with conceiving. Part of this may be explained by age, especially if their last pregnancy was achieved in their late thirties or early forties. In young, healthy women, the average monthly pregnancy rate is approximately 20%. As women age, this rate starts to decline, especially after 35 because both the number of eggs, as well as the quality of eggs decline with age. Additionally, the miscarriage rate also increases with age which can usually be attributed to the quality of the eggs.

Besides age, other causes of secondary infertility are similar to those of primary infertility, and include abnormalities in sperm quality and quantity, damaged fallopian tubes, endometriosis, ovulation disorders, uterine disorders, and one’s general overall health, such as weight, chronic medical conditions and smoking. The work up for a couple with secondary infertility includes a hysterosalpingogram (HSG), which is an evaluation of the fallopian tubes and uterine cavity, a semen analysis, and hormone testing, including an evaluation of one’s ovarian reserve.

After a thorough assessment and evaluation, the reproductive endocrinologist will create an individualized treatment plan to address each patient’s underlying diagnosis. Treatment strategies usually revolve around increasing the number of available follicles or eggs in a cycle, which increases the chances of fertilization. This is done via oral or injectable medications. During a treatment cycle, women are monitored with ultrasounds and sometimes blood hormone levels. These treatment cycles are often combined with an intrauterine insemination (IUI), an outpatient procedure which generally takes seconds to perform. In women whose sole condition is lack of ovulation, timed intercourse can be performed instead of an IUI.

There are two main risks associated with injection IUI – the risk of high order multiples (3 or more) and the risk of overstimulation. In recent years, the improved success rate of in vitro fertilization (IVF) and the ability to control the number of embryos transferred, have resulted in fewer injection IUI cycles performed. An IVF cycle typically involves daily injectable medications with frequent ultrasound monitoring and blood hormone levels. The patient then undergoes an egg retrieval which is an outpatient procedure that involves the removal of eggs from the ovaries, which are then fertilized with sperm, and then allowed to grow in a lab. After 5 days of growth, one or more of these embryos are transferred into the uterine cavity. IVF is a great option in cases where other fertility treatments have failed, cases of damaged fallopian tubes, moderate or severe sperm abnormalities and diminished ovarian reserve. IVF is by far the most effective treatment option with the highest pregnancy rates, and recent studies have suggested that it is a smart first-line treatment in any woman over the age of 35 since it is the most efficient treatment, usually resulting in the shortest time to pregnancy.

One of the major concerns couples have regarding IVF is the risk of multiples. We at RMA of New York adhere strongly to the guidelines set forth by the American Society of Reproductive Medicine (ASRM) as to the number of embryos to transfer, and in recent years, our patients have had fewer embryos transferred in an IVF cycle. Improvements in technology have led to the further development and use of comprehensive chromosomal screening (CSS). This advanced screening technique, allows for the identification of chromosomally normal embryos with high precision, and therefore the transfer of a single chromosomally normal embryo, resulting in improved pregnancy rates. Because of this, couples utilizing CCS generally undergo a single embryo transfer which reduces the chances of miscarriage and almost eliminates the risk of a twin pregnancy which is a major concern of many experiencing secondary fertility because they often desire only one more additional child.

Diagnostic evaluation is recommended to couples experiencing secondary infertility along with individualized treatment options employing the latest advances reproductive medicine has to offer.

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