What are the evaluation and treatment options for secondary infertility?

Evaluation and Treatment of Secondary Infertility

Secondary infertility requires comprehensive evaluation of both partners simultaneously, with targeted treatments based on identified causes to maximize chances of successful pregnancy.

Definition and Initial Approach

• Secondary infertility is defined as the inability to conceive after previously having at least one successful pregnancy 1
• Evaluation should begin after 12 months of regular unprotected intercourse, but earlier (after 6 months) if the female partner is ≥35 years old or if risk factors for infertility exist 1, 2
• Secondary infertility affects up to 30% of couples trying to have another child 3
• Both partners should undergo concurrent assessment to identify potentially correctable conditions 4

Female Evaluation

Medical History

• Reproductive history including prior pregnancies, outcomes, and complications 4
• Menstrual cycle characteristics (length, regularity, dysmenorrhea) 4
• Sexual history including frequency of intercourse and timing relative to ovulation 4
• Previous surgeries, hospitalizations, and illnesses 4
• Current medications and allergies 4
• Family history of reproductive issues 4

Physical Examination

• Height, weight, and BMI calculation 4
• Thyroid examination 4
• Clinical breast examination 4
• Pelvic examination to assess for:
  • Vaginal or cervical abnormalities 4
  • Uterine size, shape, position, and mobility 4
  • Adnexal masses or tenderness 4
  • Evidence of endometriosis 4

Diagnostic Testing

• Ovulation assessment with serum progesterone level at cycle day 21 2
• Uterine and tubal evaluation:
  • Hysterosalpingography for women without risk factors for tubal obstruction 2
  • Hysteroscopy or laparoscopy for women with history of endometriosis, pelvic infections, or ectopic pregnancy 2
• Transvaginal ultrasound to evaluate uterine structure and ovarian reserve 1

Male Evaluation

Medical History

• Reproductive history including prior fertility and duration of current infertility 4
• Childhood illnesses and developmental history 4
• Systemic illnesses and previous surgeries 4
• Sexual history including STDs 4
• Exposure to gonadotoxins including heat 4
• Medication use and allergies 4

Physical Examination

• Examination of the penis, including location of urethral meatus 4
• Measurement and palpation of the testes 4
• Assessment for presence and consistency of vas deferens and epididymides 4
• Checking for presence of varicocele 4
• Evaluation of secondary sex characteristics 4
• Digital rectal examination 4

Diagnostic Testing

• Semen analysis (at least one, preferably two samples at least one month apart) 4
  • Parameters include volume, pH, concentration, motility, and morphology 4
  • Collection after 2-3 days of abstinence 4
• Additional testing for men with abnormal semen parameters:
  • Hormonal evaluation 4
  • Genetic testing if indicated 4

Treatment Options

Female Factor Treatments

• Ovulatory dysfunction:
  • Clomiphene citrate for ovulation induction 5, 2
  • Gonadotropin therapy for those who don't respond to clomiphene 2
• Tubal obstruction:
  • Surgical correction if appropriate 2
  • In vitro fertilization (IVF) for severe tubal damage 2
• Uterine abnormalities:
  • Surgical correction of structural abnormalities 1

Male Factor Treatments

• Abnormal semen parameters:
  • Gonadotropin therapy for hormonal causes 2
  • Surgical correction of varicocele if present and significant 6
  • Lifestyle modifications (weight loss, smoking cessation) 1
• Assisted reproductive technologies:
  • Intrauterine insemination (IUI) 2
  • In vitro fertilization with or without intracytoplasmic sperm injection (ICSI) 2, 6

Unexplained Infertility

• Options include:
  • Continued unprotected intercourse for up to another year 2
  • Intrauterine insemination with or without ovulation induction 2
  • In vitro fertilization 2

Lifestyle Modifications

• Weight loss for obese patients 1
• Smoking cessation 1, 3
• Limiting alcohol intake 1
• Avoiding illicit drug use 1
• Consuming a fertility-promoting diet 1

Important Considerations

• Over 50% of male infertility cases can be attributed to specific conditions that may have health implications beyond fertility 4
• Men with abnormal semen parameters have higher rates of testicular cancer and general cancer 4
• Advanced paternal age increases risks of genetic mutations and certain conditions in offspring 4
• Secondary infertility after vaginal childbirth is often characterized by advanced female age and overweight 3