Secondary Infertility

Quick takeaways

• Secondary infertility is difficulty conceiving after a previous pregnancy.
• It can involve male factors, female factors, both partners, or unexplained infertility.
• Prior fertility does not rule out a current sperm, ovulation, uterine, tubal, or hormone issue.
• Age matters for both partners, but especially for ovarian reserve and egg quality over time.
• In men, changes in sperm count, sperm motility, sperm morphology, testosterone, varicocele status, or overall health can contribute.
• Evaluation usually starts after 12 months of trying if the female partner is under 35, or after 6 months if she is 35 or older.
• A semen analysis is one of the simplest and most important first tests in a fertility workup.
• Many causes of secondary infertility are treatable, and options range from lifestyle changes to medication, surgery, IUI, or IVF.

What is secondary infertility?

Secondary infertility is a clinical term used when a couple has already achieved at least one pregnancy in the past but is now unable to conceive again after a reasonable period of trying. That prior pregnancy may have resulted in a live birth, miscarriage, or stillbirth. The key point is that conception happened before.

Doctors generally use the same timing standards as other infertility evaluations:

• Under age 35: seek evaluation after 12 months of regular, unprotected intercourse without pregnancy
• Age 35 or older: seek evaluation after 6 months
• Age 40 or older, or if there are known issues: consider earlier assessment

Secondary infertility is not rare, and it is not just “bad luck.” It reflects a change in reproductive function that deserves a real medical evaluation.

Secondary infertility vs primary infertility

The difference comes down to whether pregnancy has ever happened before.

That distinction matters emotionally and medically. Couples with secondary infertility may delay evaluation because they assume the problem will resolve on its own. They may also be less likely to think of the male partner as a possible source of the issue because he was fertile before. In reality, fertility status can change significantly over time.

How common is secondary infertility?

Secondary infertility is common enough that fertility specialists see it routinely. Exact numbers vary by population and study design, but it accounts for a substantial share of infertility cases worldwide.

It may become more common as people start families later, space pregnancies further apart, or develop medical conditions over time that affect reproductive health. Because age, health status, body weight, medications, stress, and environmental exposures change over the years, fertility can change too.

What causes secondary infertility?

Secondary infertility can have one cause, multiple contributing factors, or no clearly identifiable cause. The most common categories include:

• Male-factor infertility, such as a decline in sperm quality or hormone problems
• Ovulation problems, including irregular or absent ovulation
• Fallopian tube issues, including blockage or damage
• Uterine conditions, such as fibroids, polyps, adhesions, or adenomyosis
• Age-related fertility decline, especially in women but also in men
• Endometriosis
• Sexual dysfunction, such as erectile dysfunction or painful intercourse
• Pregnancy or postpartum complications that affect future fertility
• Lifestyle and health changes, including smoking, obesity, alcohol, sleep problems, or chronic disease
• Unexplained infertility, when standard testing does not reveal a clear reason

A previous pregnancy does not rule out any of these. New issues can develop long after a successful conception.

Male-factor causes of secondary infertility

Male fertility is not fixed for life. A man can father a child and later develop a problem that lowers the chances of conceiving again. In many couples, this possibility is overlooked early on.

Sperm quality changes

The semen analysis is central to evaluating male fertility. Important parameters include:

• Sperm count or concentration
• Total sperm number
• Sperm motility, or how well sperm move
• Sperm morphology, or shape
• Semen volume

Sperm quality can decline due to age, illness, fever, heat exposure, varicocele, testosterone use, anabolic steroids, smoking, obesity, medications, infections, or genetic factors.

Varicocele

A varicocele is an enlargement of veins in the scrotum. It is a common and potentially correctable cause of male infertility. A man may have had a mild varicocele during a prior conception and later experience worsening sperm quality over time.

Hormone problems

Male fertility depends on a functioning hormone axis involving the brain and testes. Problems with testosterone, follicle-stimulating hormone (FSH), luteinizing hormone (LH), prolactin, or thyroid function can interfere with sperm production or sexual function.

Testosterone therapy and anabolic steroids

This is a major but underrecognized cause. Testosterone replacement therapy does not improve fertility and can suppress sperm production, sometimes severely. Anabolic steroids can do the same. Men who previously conceived naturally may still develop infertility after starting these agents.

Erectile or ejaculatory dysfunction

Difficulty with erections, delayed ejaculation, retrograde ejaculation, low libido, or frequent timing problems can all reduce the likelihood of pregnancy, even if sperm production is normal.

Illness, surgery, or injury

Past infections, testicular trauma, hernia repair, pelvic surgery, cancer treatment, or diseases affecting the testes can alter fertility after a prior pregnancy.

Age and overall health

Male age does not affect fertility as abruptly as female age, but it still matters. Advanced paternal age may be associated with reduced semen quality, longer time to pregnancy, and certain reproductive risks.

Female-factor causes of secondary infertility

Although this article is written for a men’s health audience, secondary infertility often involves female reproductive factors as well. A full evaluation usually considers both partners.

Ovulation disorders

If ovulation becomes irregular or stops, conception becomes less likely. Causes may include polycystic ovary syndrome (PCOS), thyroid disease, elevated prolactin, low body weight, obesity, high stress, perimenopause, or other hormone disorders.

Age-related decline in fertility

Female fertility decreases with age because ovarian reserve and egg quality decline over time. This is one of the most common reasons a couple conceives relatively easily the first time but struggles later, especially if several years have passed.

Tubal damage or blockage

The fallopian tubes must be open for sperm and egg to meet. Prior pelvic infections, endometriosis, abdominal surgery, or complications from pregnancy can affect tubal function.

Uterine conditions

Fibroids, endometrial polyps, scar tissue inside the uterus, adenomyosis, or congenital anatomic issues can interfere with implantation or pregnancy maintenance.

Endometriosis

Endometriosis can worsen over time and affect ovulation, egg quality, tubal function, pelvic anatomy, and implantation.

Pregnancy-related complications

Complications from a prior delivery or miscarriage, such as retained tissue, uterine infection, or intrauterine adhesions, may affect future fertility in some cases.

Symptoms and signs of secondary infertility

The main sign is straightforward: pregnancy is not happening despite regular, unprotected sex. But some people also notice clues that point toward an underlying issue.

Possible signs in men

• Reduced sexual desire
• Erectile dysfunction
• Ejaculation problems
• Testicular pain, swelling, or a known varicocele
• Past testosterone or steroid use
• History of mumps orchitis, STI, chemotherapy, or testicular injury
• Changes in body hair, energy, or muscle mass that suggest hormone issues

Possible signs in women

• Irregular periods or absent periods
• Very painful periods or pelvic pain
• Heavy bleeding or spotting between periods
• Symptoms of PCOS, such as acne or excess hair growth
• History of pelvic infection, endometriosis, fibroids, or miscarriage complications

It is also possible to have no symptoms at all besides difficulty conceiving.

When to seek medical advice

You do not need to wait indefinitely. It is reasonable to seek a fertility evaluation if:

• The female partner is under 35 and pregnancy has not happened after 12 months
• The female partner is 35 or older and pregnancy has not happened after 6 months
• There are irregular periods, known ovulation issues, or endometriosis
• There is a history of miscarriage, pelvic surgery, tubal disease, or uterine problems
• The male partner has low testosterone symptoms, testosterone use, prior anabolic steroid use, a varicocele, sexual dysfunction, or a history of testicular problems
• Either partner has had cancer treatment or significant reproductive tract infection

If the female partner is over 40, or if there is a known fertility issue in either partner, earlier evaluation is usually appropriate.

How secondary infertility is diagnosed

Diagnosis starts with a full review of both partners, not just the person trying to carry the pregnancy. The goal is to identify factors that may have changed since the last conception.

1. Medical and reproductive history: prior pregnancies, miscarriages, deliveries, timing of intercourse, menstrual pattern, medications, surgeries, illnesses, and sexual history
2. Lifestyle review: smoking, alcohol, cannabis, weight changes, exercise extremes, sleep, stress, and heat exposure
3. Physical exam: if indicated for either partner
4. Semen analysis: often one of the first and most informative tests for men
5. Ovulation assessment: based on cycle history, hormone testing, or ultrasound
6. Imaging and structural testing: to assess the uterus and fallopian tubes when needed
7. Additional labs: tailored to the couple’s history

Importantly, infertility is a shared issue. A complete workup usually evaluates both partners at the same time to avoid delays.

Tests for men in a secondary infertility workup

In many cases, the male evaluation is underused early on. That can waste time. A male workup is often relatively simple and can quickly uncover a treatable issue.

Semen analysis

This is the core test. It measures volume, concentration, total sperm count, motility, and morphology. Because semen results can vary from sample to sample, doctors often repeat the test if the first result is abnormal.

Hormone testing

Depending on symptoms and semen results, a clinician may order:

• Total testosterone
• FSH
• LH
• Prolactin
• Estradiol
• Thyroid testing

Physical examination

A clinician may check testicular size, evidence of varicocele, vas deferens presence, signs of testosterone deficiency, or genital abnormalities.

Additional testing when indicated

• Scrotal ultrasound
• Genetic testing
• Post-ejaculatory urinalysis for suspected retrograde ejaculation
• Specialized sperm testing in selected cases

Tests for women in a secondary infertility workup

Female testing is tailored to age, cycle pattern, pregnancy history, and symptoms. Common tests may include:

• Ovulation assessment, through cycle review, progesterone testing, or ultrasound
• Ovarian reserve testing, such as AMH and sometimes day 3 FSH and estradiol
• Pelvic ultrasound, to look for fibroids, ovarian cysts, or other structural issues
• Hysterosalpingography (HSG), to assess whether the fallopian tubes are open
• Saline sonogram or hysteroscopy, to examine the uterine cavity more closely
• Hormone tests, including thyroid and prolactin where appropriate

What’s normal vs what’s not?

There is no single “secondary infertility test.” Instead, doctors interpret a collection of findings. The table below summarizes what tends to be reassuring versus what may need attention.

“Normal” findings do not always guarantee fertility, and one abnormal result does not always explain everything. Fertility requires multiple systems to work together at the right time.

Treatment options for secondary infertility

Treatment depends on the cause, age, how long you have been trying, and whether one or both partners have contributing factors. In many cases, treatment starts with the simplest appropriate step.

1. Treat an identifiable male-factor issue

• Stop testosterone therapy or anabolic steroids under medical supervision if fertility is desired
• Treat a varicocele in selected cases
• Manage hormone abnormalities
• Address erectile or ejaculatory dysfunction
• Review medications that may impair fertility
• Improve general health factors that affect sperm production

2. Treat an identifiable female-factor issue

• Ovulation induction for ovulatory dysfunction
• Surgery or targeted treatment for fibroids, polyps, adhesions, or endometriosis in appropriate cases
• Management of thyroid disease or other hormone disorders
• Further reproductive treatment for tubal disease or severe age-related decline

3. Timed intercourse

For some couples, fertility counseling includes improving intercourse timing around ovulation. This is most useful when cycles are regular and no major infertility factor is present.

4. Intrauterine insemination (IUI)

IUI places prepared sperm directly into the uterus around ovulation. It may be considered in certain cases of mild male-factor infertility, unexplained infertility, ovulatory dysfunction, or cervical factors.

5. In vitro fertilization (IVF)

IVF may be recommended for blocked tubes, significant sperm problems, advanced maternal age, severe endometriosis, failed prior lower-intensity treatment, or unexplained infertility of longer duration.

6. Intracytoplasmic sperm injection (ICSI)

ICSI is often used with IVF when male-factor infertility is significant. A single sperm is injected directly into an egg to assist fertilization.

7. Surgical sperm retrieval

In selected male infertility cases, sperm can be obtained directly from the testicle or epididymis for use with assisted reproduction.

Lifestyle changes that may help fertility

Lifestyle alone does not solve every fertility problem, but it can meaningfully affect reproductive health, especially sperm quality and ovulatory health.

For men

• Stop smoking and avoid nicotine products if possible
• Limit excessive alcohol use
• Avoid anabolic steroids and do not start testosterone if trying to conceive without discussing fertility implications
• Maintain a healthy body weight
• Exercise regularly, but avoid extremes that impair health
• Get adequate sleep
• Manage chronic conditions such as diabetes or sleep apnea
• Reduce heat exposure to the testes when practical, such as frequent hot tubs or sauna overuse
• Review medications and supplements with a clinician

For women

• Optimize weight if underweight or overweight
• Track cycles to identify ovulation timing
• Manage thyroid disease, PCOS, or other chronic conditions
• Avoid smoking
• Limit alcohol according to medical guidance when trying to conceive
• Discuss any irregular bleeding or severe pelvic pain promptly

For couples

1. Have intercourse every 1 to 2 days during the fertile window if possible.
2. Do not rely on past fertility history as proof that everything is still normal.
3. Get evaluated together rather than focusing on only one partner.
4. Seek help earlier if age or known medical issues are in the picture.

Common myths and misconceptions

“We already had a baby, so infertility can’t be the issue.”

False. Secondary infertility is a real medical condition. Fertility can change after a previous pregnancy.

“If there’s a fertility problem, it’s probably the woman.”

False. Male factors contribute to a large portion of infertility cases. Men should be evaluated early, not as an afterthought.

“Taking testosterone will boost male fertility.”

False. Exogenous testosterone commonly suppresses sperm production and may worsen fertility.

“If periods are regular, ovulation and fertility must be normal.”

Not always. Regular cycles are reassuring, but they do not rule out all fertility issues.

“If semen volume looks normal, sperm must be normal.”

False. Volume alone says very little about count, motility, or morphology. A semen analysis is needed.

“Secondary infertility always means age is the cause.”

Not necessarily. Age may be a factor, but hormones, sperm quality, uterine changes, tubal issues, and health conditions can all play a role.

Questions to ask your doctor

If you are being evaluated for secondary infertility, these questions can help move the conversation forward:

• Could there be a male-factor issue even though we conceived before?
• Should we get a semen analysis now?
• Are any medications, supplements, or hormones affecting fertility?
• Do we need hormone testing?
• How should we time intercourse around ovulation?
• Should we evaluate ovarian reserve, ovulation, or tubal patency?
• What are the most likely causes in our case based on age and history?
• When should we consider IUI or IVF?
• Are there lifestyle changes that could realistically improve our chances?
• Do we need referral to a reproductive endocrinologist or male fertility specialist?

Related tests and terms

Frequently asked questions

Can a man cause secondary infertility even if he already has children?

Yes. A man can develop low sperm count, poor motility, hormone problems, sexual dysfunction, or other reproductive issues after previously fathering a child.

How long should you try before getting checked for secondary infertility?

Usually after 12 months if the female partner is under 35, or after 6 months if she is 35 or older. Earlier evaluation makes sense when there are known problems or risk factors.

Is secondary infertility more common than people think?

Yes. Many couples are surprised by it because prior pregnancy creates an expectation that conception should happen again quickly.

Can stress cause secondary infertility?

Stress alone is not usually the sole cause, but it can affect libido, sexual function, sleep, hormone balance, and treatment adherence. It may contribute, but it should not be used to dismiss a full medical workup.

Does age affect secondary infertility?

Yes. Female age has a strong effect on fertility, especially if there is a gap of several years between pregnancies. Male age can also affect sperm quality and time to conception.

What is the first test a man should get?

In most cases, a semen analysis is the best first test. Depending on the results and symptoms, hormone testing or further urologic evaluation may follow.

Can testosterone therapy lead to secondary infertility?

Yes. Testosterone therapy can suppress sperm production, sometimes enough to cause infertility. Men trying to conceive should discuss this with a qualified clinician before starting or continuing therapy.

Can you still get pregnant naturally with secondary infertility?

Sometimes, yes. It depends on the underlying cause, age, and how long the problem has been present. Some couples conceive naturally after targeted treatment or optimization.

Is secondary infertility the same as recurrent miscarriage?

No. Secondary infertility refers to difficulty conceiving or achieving a pregnancy after a prior pregnancy. Recurrent miscarriage refers to repeated pregnancy loss after conception occurs. The two can overlap but are not the same condition.

When should we see a fertility specialist instead of waiting?

See a specialist sooner if the female partner is 35 or older, periods are irregular, there is known endometriosis or tubal disease, the male partner has testicular or hormone issues, or either partner has a significant reproductive health history.

Bottom line

Secondary infertility means fertility has changed since a prior pregnancy. That change may involve sperm health, ovulation, age, anatomy, hormone balance, sexual function, or a combination of factors. The most important practical step is not to assume the past predicts the present. A timely, evidence-based evaluation of both partners gives the best chance of identifying the problem and choosing the right next step.

References

• American Society for Reproductive Medicine (ASRM). Patient education and committee guidance on infertility evaluation and treatment.
• American Urological Association (AUA) and American Society for Reproductive Medicine (ASRM). Guideline on the diagnosis and treatment of male infertility.
• World Health Organization. WHO Laboratory Manual for the Examination and Processing of Human Semen.
• American College of Obstetricians and Gynecologists (ACOG). Guidance on infertility workup and female reproductive evaluation.
• Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD). Infertility overview and causes.
• Mayo Clinic. Infertility and male infertility clinical overviews.
• National Institute for Health and Care Excellence (NICE). Fertility problems: assessment and treatment.
• Centers for Disease Control and Prevention (CDC). Reproductive health and assisted reproductive technology resources.