Secondary Infertility

Secondary infertility affects so many of my patients. In this episode of The Egg Whisperer Show, we will talk about the reality of easily becoming pregnant for baby number one and then struggling to conceive another child. People in this situation often don’t know what to do because this is so new to them. Let’s talk about secondary infertility: the causes, treatments, and some of my tips.

This is a really good article to share with the people in your life, so they know how to support you going through something that can be soul-crushing. I’m a very positive person, but I understand how hard it is to be a fertility patient. So, my staff and I do everything possible to make it as easy a process for my patients.

Now imagine I am showing you a picture of a beautiful vacation destination with snow-capped peaks above a lush forest reflected in a glassy lake. I’m sitting here in my office, not far from San Francisco, and I want to go to this stunning place.

You’re probably wondering, why is she talking about this picture? What does this have to do with a medical condition called secondary infertility? Well, if you’re sitting somewhere and want to go somewhere else, you need to plan for it. I can tell you that if I wanted to travel, I would probably do online research, get the weather forecast, get maps out, call my friends. I may need to go to a travel clinic to get vaccines before I travel.

I need to plan for my trip. That’s what we do when we want to go somewhere. Planning is essential. When it comes to fertility, I want to teach people that you can be just as proactive about planning your future family as you would be planning an extravagant, extraordinary trip for yourself.

If only I had known

You don’t just have to stumble upon pregnancy, thinking, “We were kind of thinking about it, but don’t really know.” I want to change how we plan families in this country and treat pregnancy as a very serious medical thing to be as planned and careful as possible. Everyone should have as healthy a pregnancy as possible without ever looking back and saying, “shoulda, woulda, coulda.” Or, “If only I had known.”

In my position, I see patients who come to me, and they say, “Hey, why didn’t anyone teach me these things?” That’s why I’m doing this show. I want to be that person who says, “Hey, everybody, these are the things that you can do.”

You can be proactive. You can learn more about yourself and your body — before you start having your family, especially if you want more than one child. An article recently was published on Forbes.com that asked, very simply, “What causes infertility?”

Factors at play

When we think about secondary infertility, meaning having trouble getting pregnant for your next baby when you didn’t have any trouble getting pregnant for your first, it’s a lot of the same issues.

What could those issues possibly be? Well. It could be age. It could be female factors, such as:

• fibroids in the uterus
• blocked fallopian tubes
• endometriosis
• or tubal issues

It could be male factors, such as:

• slow swimmers
• or not enough swimmers

It could be your lifestyle. We’ll talk a little bit more about that. Stress can also be a factor. I will share with you my tips about what you can do about stress.

The link between age and fertility

First, I want to point out how significant age is when it comes to fertility and healthy pregnancy. The CDC came out very recently, saying that for the first time, women in their thirties were having more babies than women in their twenties.

When people hear this information, they might think that women in their thirties are more fertile than women in their twenties. What it actually means is that older women are having the babies, and so more women will have problems having their second or next child.

We see more people with secondary infertility as our society delays childbearing. Studies show the risk of having a baby with a chromosome issue or a miscarriage goes up as we get older. This isn’t about me scaring people. This is just about education. I want to educate people about the viability of an egg at their age. I’ll also provide a link to a study showing the connection between age and pregnancy loss rate in a chart.

Don’t believe the hype

Another very helpful article recently came out by Dr. David Adamson, one of the most well-known and well-respected fertility doctors and past president of the American Society for Reproductive Medicine.

Dr. Adams wrote a blog saying, please ignore the hype of celebrity pregnancies at older ages. Fertility does decline with age. We hear about these celebrity pregnancies all the time. But they’re not necessarily as open and honest about where the egg came from.

Let’s say the patient (or celebrity) is 46, 47, 48, 49, or 50. But we know that the chance of pregnancy with a 50-year-old egg is close to 0.1%, if not lower. So, these women are being more creative about their family building. If women want a pregnancy at 50, certainly the technology is there for them to freeze their eggs in their thirties so that they can achieve that later on.

Get ahead of infertility

Another article also came out titled, “Why you should be wary of ovarian reserve testing events at fertility clinics.” If you’re a fertility doctor, you see things like this, and you think, whoa — it’s as if there’s some sort of conspiracy out there where fertility doctors are trying to scare people into learning about themselves.

And this couldn’t be further from the truth. Anything that promotes fertility awareness to me is pretty cool. If doing testing can save one patient from becoming a fertility patient in my clinic, that’s the goal.

She may be able to learn something about herself earlier that will allow her to make changes, so she has a baby earlier. That’s being proactive and pretty neat. The misleading part of the article stated that women should start testing after age 35 if they’ve been trying for a year or more. If you’ve heard me on this show, you heard me say over and over again: Get your levels checked. Get tested. Get ahead of infertility.

Are you emotionally prepared?

But before you get your levels checked, you should realize there’s a very emotional component to it. Getting your FSH or your AMH level checked isn’t like getting your blood sugar checked, or your cholesterol checked.

When you go into the doctor and find out your cholesterol is too high, you don’t leave the office crying because someone told you that you’re going have a hard time having a baby. So, when it comes to getting a test done, ask yourself, what are you going to do with that information? Are you emotionally prepared to hear the information one way or another? If you’re not emotionally prepared, wait until you are ready to talk about this very personal test that can be done at a fertility clinic.

A step-by-step process

If you want to get the testing done through me, it’s quite simple. You can go to the website, eggwhisperer.com, and follow the step-by-step process. We’ll get you registered in my system and send you out a lab slip. I will review the results with you, and we can make a fertility plan together.

I can talk to you about when you should get your next set of levels done. Those levels are the FSH, estradiol, and AMH. FSH and estradiol are timed tests to your menstrual cycle. We call them “Cycle Day Three Tests.” These tests are done two days after your period starts.

The other test is the AMH test, a test that can be done at any time in your cycle. If you are on birth control pills, you should let your doctor know first because there are certain times that you would want to do a test like this that might be better than others.

So aside from the blood work, you also want to have a complete pelvic ultrasound looking for fibroids or cysts on the ovaries, such endometriosis, also known as endometriomas. That is what we call a cyst of endometriosis on the ovary.

First, the diagnosis

If you were having some sort of chest pain and you went to the doctor, they wouldn’t just give you medications. They would likely do an imaging study, perhaps a chest x-ray and echocardiogram. When it comes to fertility medicine, sometimes patients are given medication without having all the workup and tests done first to figure out what the diagnosis is.

I’m hoping that by doing this show, I’m teaching people about the things that they can learn about themselves. Perhaps, if you haven’t had a pelvic ultrasound done yet, you should, to see if you have something like a polyp, a fibroid, or something else that might get in the way.

How are your swimmers doing?

Let’s take a trip to the beach on a sunny day with a lot of people happily swimming in the waves. This looks fun. I wouldn’t mind hanging out on a beach somewhere. It makes us think about the other kind of swimmers. How your swimmers are doing? Are your swimmers just kind of standing there? Are they going in a forward direction?

You want to get the swimmers checked. It’s a simple test — a semen analysis — and can be done at a fertility clinic. One company does a home semen analysis test. They ship you a temperature-controlled kit. You produce a sample and ship it back, and the results look just as good as they would look from an andrology lab at a fertility clinic.

Talk to your doctor about a way to get your swimmers checked that’s convenient for you so that you can learn about whether you should be changing your diet habits. See a urologist to do more advanced sperm testing.

So, if you’re a woman, get your levels checked for fertility. If you’re a guy, get your swimmers checked. And guys, it’s certainly a lot easier to get your sperm frozen than for a woman to get her eggs frozen.

Lifestyle and diet

The other thing we need to look at is lifestyle and your diet. How many sodas are you drinking a day? We hear so much about how sodas, especially diet sodas with artificial sweeteners, are not good for us. The liners in the aluminum cans have BPA in them, and they are potentially endocrine disruptors and also can affect the quality of our gametes, meaning egg and sperm.

Look at what you’re doing in terms of the foods you’re eating and what you’re drinking. Think about the makeup you’re using. See how you can live as nontoxic a life as possible. Live your best life ever.

Recently, a lot was trending about how sperm counts are going down over time for men. I joked that it’s because of the pizza and beer that we’re eating and drinking in this country. The serving size for a glass of wine for a woman is about four ounces. You look at that glass, and you say to yourself, I wonder if the entire bottle is in this glass? Then you know, that is too much.

Sometimes it’s better just to stop altogether than to decrease your consumption of these things. If you’re having a hard time figuring out what is too much, perhaps it’s better to cut it out completely, if you’re trying for another baby. Certainly, you won’t be drinking in pregnancy anyway, so it’s not a bad idea to get used to that right now.

Making healthy changes

When it comes to nutrition and diet, you may need help creating a change. If you’ve had a certain diet for so long, you can meet with a nutritionist who can guide you. We’ll post information about someone who can work with you remotely as well as someone who can help you with more vigorous exercise plans. We have a local training coach who can do that with you over the phone, by Skype or text to be there for you.

I work with both of these folks to help my patients get into their best personal shape ever. They can accomplish their goals with their lifestyle so that perhaps they can have an easier time getting pregnant. And that’s what I do — teach my patients what they need to know, so ideally, they can get pregnant without my help.

I know that sounds a bit contradictory. Why would a fertility doctor not want patients to come in? My wish is for patients not to need my help. But if a patient is going to see me, and we end up doing a treatment, I want them to be in a position to have the best chances. If we address these things first, then hopefully the treatment will be successful.

Not everything works the first time. But if we’re working on the lifestyle piece, at least we don’t look back and say, “Oh, we wasted time not dealing with that upfront.”

Address your stress

The other factor is stress. Another good friend of mine, Dr. Lora Shahine, will be on our show talking about her book, Not Broken, which addresses miscarriages and recurrent pregnancy loss. If you have a question about that, please email us so we can answer your questions during the live show.

Shahine wrote an excellent blog article about stress and fertility. If I said to someone, “Are you stressed?” and if the answer is yes — I don’t need to do a test there. If you know you’re stressed, then it’s essential to ask yourself: What do I need to do to reduce my stress? There are so many ways of doing that. Look at your partner and your relationship. Think about ways you can support each other. Talk to a therapist. See an acupuncturist. Do something for yourself.

Once a week, do things that you enjoy: hang out with your friends, be more social. These things can help with stress so that, when you’re ready to try to conceive, your chances will be potentially a little higher with lower stress.

Consider egg freezing

When it comes to treatment options, sometimes people are surprised when I say consider egg freezing. An article just was published in Cosmo about a 34-year-old who was married and wanted to freeze her eggs. That sounds kind of counterintuitive. People may think egg freezing is just for single people. In fact, it isn’t.

There are so many reasons why someone might want to egg freeze if they’re in a relationship. One reason could be if you want more kids and don’t necessarily want frozen embryos to sit around. If someone’s thinking about egg freezing, even if it isn’t for them, at least they’re going to be more fertility aware. Egg freezing is one of the treatments you can use to prevent secondary infertility if you start your family in your thirties. You can be one of those patients who come in at 40 and says, “Aimee, I’m going to use my frozen eggs.”

This is an exciting reality for people.I have patients over 40 whose eggs I froze when they were in their thirties, and now they’re pregnant with those 30-year-old eggs. That’s pretty exciting for me to share that with all of you.

Testing recap

Some of the tests you should do for secondary infertility are very similar to the tests that you would do for primary infertility. These tests include:

Crucial Blood work

You want to do blood work for FSH, Estradiol, the AMH test, and other hormones such as TSH, prolactin, and vitamin tests, including vitamin D.

Depending on your body size, you might want to consider a glucose test or a hemoglobin A1C and a lipid panel to make sure you’re in the best shape of your life, and you’re getting the support you need from other medical doctors. Ask yourself: Are there are things that you need to work on to get those levels better before you start a pregnancy?

• Semen Analysis 
• Pelvic Ultrasound

A pelvic ultrasound will look at your uterus to see if there are polyps, fibroids, or cysts of endometriosis.

• HSG akaTube test

A tube test is a good idea. You might think that sounds silly and wonder: Why wouldI need to make sure my fallopian tubes are open if I’ve already had a baby? I tell my patients that if you’ve had a pregnancy in your uterus, that means one of your tubes was open, and you ovulated from that one side. We actually don’t alternate where we ovulate from: You don’t ovulate every even month from your right side and every odd month from your left. If you knew which side was open, you would know when to try to conceive. So a tubal assessment can be important for patients with secondary infertility.

And I recommend pain meds — a valium and a driver to deliver the meds because an HSG can be very painful. When you read the stories online, you think it’s one of the most horrible tests a woman can have. If someone were to tell me, I’m going to do something that’s going to cause you pain; I would expect to receive pain medication so that I would not have pain.

• Advanced Sperm Testing

There also is advanced sperm testing to look at DNA fragmentation in the sperm as well as epigenetic changes in the sperm. There are things that you can do to improve the sperm DNA. I have patients who get pregnant with baby number one with an IUI (intrauterine insemination) — the turkey baster approach. I tell these patients: “Freeze your sperm. Freeze your sperm.” So, when you return for baby number two in a few years, we can use the younger sperm with better DNA.

• Family Prep Panel

The other thing to do is a family prep panel to make sure that both the egg and sperm contributors don’t share the same mutation so that a disease is not passed on. That is still something that I ask my patients to consider doing with secondary infertility.

Treatments

• Best personal shape ever

You hear me say this all the time. Be in your best personal shape ever. You’re feeling great about yourself. You feel like you’re healthy — you’re eating right, you’re doing self-care. That means you’re also able to take care of your family in the best way. It means you can take the time you need to get the treatment you need. That is certainly number one — top of my list. Anything you can do to help your general health is also going to help your fertility health.

Other treatment options are the same as with primary infertility:

• Fertility pills

You can do fertility pills with or without IUI and IVF.

• Fertility Shots

You can do fertility shots with or without IUI as well.

The most important thing before you choose a treatment is figuring out what the diagnosis is. Do all the tests that I listed or whatever tests your doctor thinks are best for you, given your personal story. Once you’ve done the test, you see what’s wrong. Then you can say, this is the treatment that will treat the diagnosis I have learned about myself.

As always, get your levels checked. Get ahead of infertility. Go to TUSHYMethod.com to learn more!

Be sure to tune into this show. Some of the upcoming episodes are covering important topics, such as miscarriage and recurrent pregnancy loss.

Birth control after fertility treatment?

I’ll take some time to answer a Facebook question: Is it possible for a woman who was unable to conceive naturally and who used IVF for baby number one to get pregnant naturally for baby number two?

I see that all the time, and it’s really fun for a patient to reach out to me and say, “Aimee, remember me? We did all this treatment, and now I’m pregnant naturally.” That means you had the perfect golden egg and sperm combination in that given cycle.

One of the reasons is endometriosis. Women with endometriosis find that pregnancy actually treats it. You can’t treat the endometriosis until you get pregnant, in many cases. Once you’re pregnant from fertility treatment, the pregnancy will heal the endometriosis so that you’ll have an easier time getting pregnant for baby number two.

I get emails all the time from my patients who say, “Aimee, this is the craziest thing ever. At my postpartum visit, my OBGYN wants to put me on birth control pills. I can’t believe it. We tried so hard to get pregnant!”

It’s not a silly idea to think about family planning after struggling so long with fertility treatment, especially if you don’t’ necessarily want baby number two to come so quickly.

Waiting between pregnancies

If I have a patient who may be 40 years old when they deliver and if we didn’t bank embryos, I’ll say: As soon as you leave Labor and Delivery, you’re going to come here, and we’ll do some testing. Then we’ll talk about what our chances are for conceiving baby number two.

You don’t necessarily have to wait two to three years. You can always bank embryos first. Depending on how you delivered — whether it’s a vaginal delivery or a C-section — the general recommendation is 18 months, interpregnancy interval for someone who has had a C-section. Sometimes it’s shorter.

I would talk to your doctor about what their recommendations are for you. I like patients to wait at least six months or more after a vaginal delivery. That gives the body time to heal and all the reserves to get restored.

Thank you for joining me for this important topic that affects so many people. As always, please comment, send questions or suggested topics for future shows.

Send me a note: [email protected]

You can also catch more of me and topics like this through the Egg Whisperer Show. The episodes are live-streamed on YouTube, Facebook, and Instagram and on Wednesdays at 4 PM PST. Subscribe to the podcast too!