Mrs. M walked into the clinic with her beautiful daughter Maya, aged 5. She is a happily married woman and conceived Maya within their first 6 months of marriage. Her pregnancy was well and Maya was delivered via caesarean delivery.
The obvious question popped up in my mind, “How can I help you?”
“Well, we want another child and we have been trying for a second baby for the past one and a half years. I just don’t understand why I am not getting pregnant. I got pregnant with Maya easily. Surely we are not suffering from infertility. But why it is not happening again?”
She is just one out of many women who find it difficult to believe that they are struggling for a second child or what is medically known as secondary subfertility.
What leads to secondary subfertility? Let’s find out right now.
Age factor
In a natural pregnancy, age is an important determinant of success rate. This is mainly because of a woman’s egg quantity as well as quality decline with age. Generally, a woman’s fertility starts to decline rapidly from the age of 35-37 onward compared to when she was younger. At a younger age, fertility declines more slowly.
This is the reason why doctors (and your mother and mother-in-law too!) will advise you to complete your family earlier than later – your chances to conceive for the second time may not be the same compared to when you conceived your first child.
Ovarian reserve (egg numbers)
A woman’s age does play a crucial role in her ovarian reserve. Ovarian reserve means the number of eggs that you are left with, which correlates with your chances to get pregnant. The lower the ovarian reserve, the lower your chances to get pregnant.
Besides age, other factors can decrease your ovarian reserve. Ovarian surgery (for ovarian cyst) and endometriosis can decrease your egg numbers. If you have previous surgery to your ovary and find it difficult to conceive again, maybe it’s time to see your doctor.
Ovulation Problem
Ovulation is crucial for a natural conception. When ovulation is irregular, it increases your difficulty to get pregnant naturally simply because you cannot time your ‘fertile’ window accurately.
You may be wondering, why has ovulation become irregular now and not before when you conceived your first child? For one, your weight has an effect on your ovulation. If you have put on weight after your first child, it can affect your ovulation and your monthly period cycles.
For some who have been diagnosed with Polycystic Ovarian Syndrome (PCOS), period irregularity may start later in life. In PCOS, the woman is not ovulating regularly.
In this situation, once all the other causes are excluded, the simplest thing to do is to make the ovulation regular. In most cases, weight reduction together with some fertility medication is sufficient.
Tubal factor
Women have a pair of Fallopian tubes attached to the womb. This tube picks up the ovulated egg and fertilisation of the egg by the sperm happens in the tube. If the tubes are damaged or blocked, chances to get pregnant naturally are very much reduced or perhaps even impossible (in the case of bilaterally blocked tubes).
Fallopian tubes are at risk of being damaged or blocked when a woman undergoes any kind of pelvic surgery including a caesarean section, ovarian cyst removal, or removal of a uterine fibroid.
Pelvic infections (such as Chlamydia) can also lead to tubal blockage. Thus, a woman with these risk factors should check the patency of their tubes.
Endometriosis
Endometriosis is not an uncommon cause of secondary subfertility. Endometriosis can lead to an ovarian cyst, which can have a direct negative effect on egg numbers. Endometriosis can also lead to tubal blockage due to continuous bleeding and scar formation. While there is no magic treatment that can eliminate endometriosis, if diagnosed early, it can be controlled while in some cases, fertility treatment can be offered before the condition worsens.
Uterine factor
The womb or the uterus is rarely the cause of subfertility. If you had successfully delivered a child before, it means that your uterus can carry a pregnancy. However, after major uterine surgery such as removal of numerous uterine fibroids, the anatomy of the uterus can be distorted and the lining of the uterus where the pregnancy implants can be damaged.
Another common uterine factor is a gynaecological condition called adenomyosis. In this condition, the uterus is gradually getting ‘swollen’. Severe adenomyosis has been linked with reduced fertility.
Sperm quality
To have a successful pregnancy, you need a healthy egg and a healthy sperm. Even though male fertility declines slowly than their female partner, sperm quality is still an important factor in secondary subfertility. Factors such as cigarette smoke, unhealthy diet, and pollutants are known to reduce the quality of sperm. Thus male partners need to get themselves checked together with their wives.
Smoking, for both women and men, has an adverse effect on their fertility. Long term smoking can lead to poorer egg quality. Likewise, smoking also reduces men’s sperm quality even though his sperm quantity is normal.
So, you could have easily conceived your first child, but continuous smoking can make it harder to conceive your second child.
Stress
Stress is widely linked to subfertility. It does not only work-related stress but the stress of caring for your first child. You may have sleep deprivation, stress with time constraints, and pressure juggling between work and child care. These can make it more challenging to try for a baby during the fertile period of the woman.
Change in health status
The older you get, chances are that you may have developed health conditions such as high blood pressure and diabetes. When these conditions are not well controlled, it reduces your fertility. It is important to have regular health check-ups and initiate early intervention if needed.
The above are some common causes of secondary subfertility. If you are trying for another baby and are having difficulty in conceiving, take the necessary steps today to get yourself checked. Last but not least, remember: “You have done it once, and you can do it again.”
By Dr Agilan Arjunan,
Consultant Gynecologist & Fertility Specialist,
KL Fertility Centre
