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Millions of women of childbearing age in the United States who have one biological child have difficulty getting pregnant again, according to estimates from the Centers for Disease Control.

Secondary infertility, as it is called, isn’t talked about nearly as often as primary infertility, but is still a serious concern for millions. Most women and couples assume that once they have one child, infertility issues in the future will not be a problem. This is not the case.

The truth is that a high percentage of infertility cases are actually related to secondary infertility. Despite this, many people experiencing secondary infertility won’t seek treatment because they’ve been fertile in the past. This leads to frustrating attempts for a child, attempts that can last for years with no success.

The causes for secondary infertility are usually similar to the causes for primary infertility. Worsening medical problems, often influenced by lifestyle factors, can explain why couples cannot conceive. Male factor problems like sperm abnormalities or erectile dysfunction, and female factors like ovulation issues, endometriosis, and uterine fibroids are all common causes for secondary infertility. Women who have had pelvic surgery, like a cesarean section, may have pelvic adhesions leading to tubal occlusion.

When it comes to lifestyle, most parents will probably agree that life changes drastically once you have a child. Priorities change, and there is often less time to focus on your own health. This sometimes means weight gain and poor diet, both of which may contribute to infertility.

As a general rule, if you are under 35 and have been having unprotected sex for a year with no pregnancy, it is probably time to see an infertility specialist. This is true whether or not you’ve had prior children.

Secondary infertility can be as much if not more of a strain on relationships compared to primary infertility. Expectations of when and how many children to have are forced to change. Many couples worry about their current children and their lack of siblings. This is why it is important for couples to understand that secondary infertility is a very real possibility, and that it may be time to seek an evaluation.