‘I felt like it’s my fault’: When it’s much more difficult to get pregnant again

The first time YES 933FM DJ Lim Peifen thought about going to a fertility doctor was after she had tried for a year to conceive a second child. 

“I wanted to space the pregnancies out, about three to four years, so when we started trying, we didn’t think much as the first pregnancy came easy,” she said at a webinar organised by I Love Children, a non-profit organisation focusing on fertility wellness and parenthood, in November last year.  

Through her doctor, she found out that one of her fallopian tubes was blocked – a possible reason why she couldn’t get pregnant. 

“When I found that out, I felt inadequate. I felt like it’s my fault because it’s me, right? For a while, I felt a little dejected. There was a bit of a psychological battle there,” said Lim.

Despite the couple making adjustments to their lifestyle, which included eating more healthily, cutting down on social drinking and Lim asking to be taken off the morning show at the Chinese radio station, she still wasn’t able to conceive. 

But in late 2019, just as she was about to get a second opinion on surgery to unblock her fallopian tube, Lim discovered she was pregnant: “You can imagine how happy we were, right?”

At week 11 of her pregnancy, however, she had a miscarriage. In hindsight, Lim said it was losing the pregnancy that gave her the courage to go ahead with the surgery.

Shortly after, she fell pregnant again and gave birth to her second child on Oct 1, 2020.

BEING UNABLE TO CONCEIVE THE SECOND TIME

The World Health Organization describes primary infertility as when a pregnancy has never been achieved by a person, while secondary infertility refers to when at least one prior pregnancy has been achieved.

What Lim experienced is secondary infertility, since she had been pregnant before, said Dr Hemashree Rajesh, a senior consultant at the Department of Obstetrics and Gynaecology at Singapore General Hospital (SGH).

In secondary infertility, the previous pregnancy (or pregnancies) could either be a successful or a failed one, she explained.

‘PARTICULARLY DISTRESSING FOR COUPLES’

Dr Roland Chieng, the founding medical director of Virtus Fertility Centre, told CNA Women that approximately 30 per cent of patients who come to the clinic experience secondary infertility.

“Research has shown women struggling with infertility experience the same level of depression as women with cancer and heart disease,” he added.

While anger, stress and depression are common among women with primary infertility, the emotions of women who had previously given birth and now can’t conceive “can be very different”, he noted. 

“In addition to feeling disappointed and upset, they may experience shock, particularly if conception was relatively easy the first time around,” said Dr Chieng.

“Many of them want a larger family and are frustrated when things don't move on,” Dr Hemashree added. 

They also feel guilty, Dr Chieng added, perhaps for not trying for a second child earlier. They may also face pressure from family members, such as older children who want a sibling.  

And it’s not just the woman who is affected. The man feels it just as much. 

Frances Yeo, a psychologist at Thomson Medical Centre and one of the speakers at the I Love Children webinar, said that husbands get stressed, too, especially when their wives show them a negative pregnancy test result.  

POTENTIAL CAUSES OF SECONDARY INFERTILITY

The medical assessment for both primary and secondary infertility is the same, said Dr Chieng, with advancing age, less frequent sex and emotional factors associated with work and family stress, all contributing to “lower fertility potential”. 

“The factor that age plays in infertility is greater due to many starting pregnancy planning later and marrying when they are older. We know fertility declines more rapidly after the age of 35 as the egg quantity and quality diminishes,” he explained.

Other possible causes of secondary infertility include: 

• Ovulation dysfunction. Being overweight may result in hormone imbalances, which interfere with the release of eggs. 
• Damaged or blocked fallopian tubes. In some cases, a woman’s fallopian tubes (where fertilisation occurs) are damaged due to gynaecological conditions such as pelvic inflammatory disease and endometriosis. The latter affects one in 10 women of reproductive age, said Dr Anupriya Agarwal, a senior consultant obstetrician and gynaecologist at Advanced Centre for Reproductive Medicine (ACRM) Gleneagles. In other cases, there may be a blockage in the tubes due to an infection. 
• Common gynaecological conditions such as uterine fibroids (benign growths in or around the womb). As well, adenomyosis, where tissue from the womb lining grows into the muscular layer of the womb, and may develop due to a woman’s advancing age, impacting her fertility, said Dr Agarwal. 
• Other conditions like ovarian cyst treatments, treatment for cancer or other medical conditions can also affect a woman's fertility, Dr Hemashree said. 
• Any complication, such as infection, excessive bleeding or hospitalisation that happened during the last pregnancy and delivery, also needs to be looked at, said Dr Chieng. 
• Impaired sperm production, function or delivery for men. “Just because a man has fathered a child in the past doesn’t mean his sperm function hasn’t significantly deteriorated over time,” Dr Chieng said.

GOING FOR A FERTILITY HEALTH CHECK AND TREATMENT OPTIONS

Dr Janice Tung, a consultant obstetrician and gynaecologist at Thomson Fertility Centre, said in a media release by I Love Children that it’s a good idea for couples to go for a fertility health check, whether they are having difficulties conceiving or not. 

A fertility health check helps couples understand their fertility health so that they can seek timely treatment, optimising their chances of conception before it is too late, she added.

If the woman is below 35 years and has no risk factors for infertility (such as age, hormone imbalance, smoking), the couple should try for a year to conceive.

If the woman is above 35, Dr Agarwal recommends the couple seek help after six months of trying. You should also consider seeking help earlier if you have irregular menstrual cycles or other known risk factors for fertility issues.  

There is a silver lining when it comes to secondary infertility though, and that is that treatment for it is “likely to be more successful because of a previous pregnancy”, said Dr Chieng. 

At the webinar, Dr Tung discussed these main modes of fertility treatment, which apply to both primary and secondary infertility:   

• Surgery. For instance, in Lim’s case, to unblock one of her fallopian tubes. In other women, it could be the removal of ovarian cysts or polyps (benign growths in the womb lining) from the uterine cavity.
• Ovulation induction for women who aren’t ovulating regularly. This is where you take medication, either orally or via injection, to help you ovulate.
• Intrauterine insemination (IUI) or artificial insemination. Your husband’s sperm is concentrated and injected into your womb at the time of ovulation, so that it’s closer to the egg.
• In-vitro fertilisation (IVF). The sperm fertilises the eggs in a laboratory (in-vitro means “in glass”), and the resulting embryos are then returned into the woman’s body for conception.

It’s possible for women to overcome secondary infertility and get pregnant, said Dr Agarwal, depending on their ovarian reserve (the number of eggs remaining in the ovaries) at the time. If the reserve is low, then your chances are low; if it’s normal, then you have a fair chance at conceiving. 

“Some women are born with a very low number of eggs or they have low ovarian reserve due to a previous ovarian cyst surgery or endometriosis,” she noted. 

WHEN TO SEEK COUNSELLING HELP 

Couples should seek help when they feel strong anxiety in their efforts to conceive, and when they feel the need to obsessively control everything about it, suggested Yeo, the psychologist from Thomson Medical Centre who spoke at the webinar. 

Inappropriate guilt or avoidance behaviours, such as avoiding people with babies or the baby and children’s section in stores, might be signs to look out for.

Support groups, such as Fertility Support SG, are important as they allow women to connect with others who have gone or are going through the same issues, said Dr Chieng.

“It is a safe place where they can share their stories, talk openly and honestly without fear of judgement, and provides a great outlet for sharing fears, emotions and disappointments.”

At the same time, Yeo said that it will be stressful trying to conceive, especially if you and your husband have been trying and nothing seems to work.  

To deal with the uncertainty and stress, her advice is to recognise what you can control and what you can’t.

“If you can identify your source of stress, and be able to do things to manage that, those are things you can control – such as exercise, cutting down on your drinking, watching your diet and having good sleep,” she said.