Secondary infertility refers to couples who have conceived previously and then remain unsuccessful after 12 months attempting a further conception. Theoretically, the term applies if a woman has ever conceived, however, in practice, clinicians consider the relevance to the current relationship. Many factors may be at work with the most frustrating ‘idiopathic’ or ‘unexplained’ very common. The condition is no less frustrating than primary infertility where a couple have never conceived, and demands equal attention. Age is important when considering how and when to investigate, with maternal age 35 years the determinant. The clinical approach to couples with secondary infertility is similar to primary infertility as there is an overlap in causation. A detailed history searching for possible causes in both partners is the first step. If a successful pregnancy has resulted from the union, interval factors such as intercurrent disease or injury may be relevant. Female factors such as age, endocrine and infectious disease or anatomical disorders of the pelvis need to be considered. Underlying genetic abnormalities may be suggested if repeated miscarriages occur. Blood tests for autoimmune, endocrine and genetic conditions are frequently arranged. In males, trauma, infection, surgery, lifestyle, toxic exposure and idiopathic causes need to be considered. The male evaluation relies heavily on the result of a semen analysis after three days abstinence. The WHO fifth centile parameters of 15 million/ml, 32% rapidly progressively motile and 4% strictly normal morphology apply to “normal fertility” in males. There is an intrinsic fluctuation so the test may need to be repeated after an interval if any doubt. It is not unusual to find that couples who have conceived easily on one occasion are found to have a male factor on subsequent evaluation. In this circumstance, the initial conception seems to have been a ‘lucky’ event against the statistical odds rather than a repeatedly likely event. Assisted reproductive procedures with ovulation induction and timed insemination, or IVF with or without ICSI (intra-cytoplasmic sperm injection) are often successful in overcoming male factor anomalies. Women are generally more complex with regards to fertility matters. The evaluation involves assessing oocyte (egg) reserve, which typically diminishes with age. The AMH (Anti-Mullerian Hormone) blood test gives an accurate assessment of reserve but unfortunately doesn’t assess quality. The efficiency, regularity and timing of ovulation needs to be assessed with blood or urine tests. Anatomical evaluation usually requires a combination of ultrasound and either tubal patency testing or a surgical procedure called a laparoscopy, where a small incision in the umbilicus is used to inflate the abdomen and assess pelvic organs. Certain conditions such as adhesions, endometriosis and fibroids may be treated, improving subsequent fertility chances. Women’s Hea lth Secondary Infertility When the second time around is not quite as easy as the first … Dr Gary Swift Obstetrician & Gynaecologist 38 Pindara Magazine Autumn 2015
Pindara Private Hospital Magazine - Issue Four
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