Dr Rania Habib (Host): The CDC estimates that around 13% of women aged 15 to 49 in the U.S. will experience some degree of infertility while they are trying to get pregnant.

This is BayCare HealthChat. I'm your host, Dr. Rania Habib. Joining me today is Dr. Astrid Mondaca, a board-certified OB-GYN in Tampa, Florida. She is here to discuss secondary infertility with us today. Welcome, Dr. Mondaca. We are so excited to delve into this very important topic.

Dr. Astrid Mondaca: Thank you. I'm excited to be able to share my experience and also information about secondary infertility for those of you who would like more information.

Host: What is secondary infertility, Dr. Mondaca? And how common is it?

Dr. Astrid Mondaca: So, secondary infertility is when you're unable to conceive or carry a pregnancy to term after having given birth before. It mostly affects about 15% of couples.

Host: And is that secondary infertility generally from the mother's side or can it also be from the father's side?

Dr. Astrid Mondaca: Most of the time it's mostly from the mother's side because they're the ones that are carrying the pregnancy. And we will talk more about the male side of infertility as well.

Host: Perfect. What are some of the most common causes of secondary infertility?

Dr. Astrid Mondaca: So, some of the causes for female infertility include diminished ovarian reserve; an ovulation dysfunction, meaning they're not always ovulating each month; a tubal factor, meaning like there could be a blocked tube; or a uterine factor, for example, polyps or fibroids that can be found inside the lining of the uterus. As well as other factors like a thyroid dysfunction or a prolactin elevation, which will cause people not to ovulate and also have breast secretions; as well as male factors, which include sperm count, sperm mobility, sperm morphology. And usually, we do test males as well because 50% of the chance it could be a male factor.

Host: Absolutely. So, if a woman or, you know, they suspect that her husband is having issues that are contributing to the secondary infertility, when should a patient see a doctor?

Dr. Astrid Mondaca: So, usually my recommendation is if you've been actively trying to conceive and you're under the age of 35 and it's been over a year, we usually want you to seek help. And you could seek your local OB-GYN, as well as if you're over the age of 35 and you've been trying actively for six months, with timed intercourse, of course, you would want to seek help at that point.

Host: Dr. Mondaca, what is the timing for infertility evaluation?

Dr. Astrid Mondaca: So, it's really important for the timing of infertility for females. So, what usually we start off with are day 3 labs because we want to make sure that the hormone levels are normal. So, I usually will order like FSH, estradiol, a thyroid panel, prolactin. And sometimes I will order an anti-Müllerian hormone, which kind of gives us the ovarian reserve for females, as well as day 21, a progesterone level to make sure that women are ovulating. As well as a transvaginal ultrasound, let's say, during ovulation to look at the follicle counts on the ovaries, to also look for ovulation or any abnormalities within the uterine cavity, like we've talked about fibroids or polyps. We don't always see endometriosis on an ultrasound, but sometimes we want to also look at a physical exam as well. Make sure there's no uterine anomalies, like a heart-shaped uterus or any scar tissue or septums in the uterus as well.

Another workup would be like a hysterosalpingogram, which is contrast that we put through the cervix to check for a tubal blockage. Usually, that could help people because if there's a partial blockage, that contrast could unblock the tubes and you have a higher chance of fertility after that exam. If there is a blockage, then we know that it's going to be more difficult to conceive. So, at that point, sometimes we need to refer you to a specialist.

Host: Now, when someone comes to see you for that detailed workup, how long on average should they expect that to take?

Dr. Astrid Mondaca: Well, on average, the female part could take a few months because it all depends on the cycle. So, usually, when you get your period, we call that the first day is day one of your cycle. So, you'd have to do some blood work day 3 and then an ultrasound day 12 to 14, because that's the most common stage of when you would ovulate and then day 21 progesterone levels, and then go from there if we need to proceed with the hysterosalpingogram.

With males, it's very easy. All they need to do is give a sperm sample. And most of the time, it's a 40-50% chance that it could be a male factor. So, I usually stress to my patients, which is really hard because a lot of the males don't want to do it, and they don't think they have an issue, so it's super tough to get them to do one. But it's so easy, all they need to do is refrain from any ejaculation two to five days before the test. They can even do it at home if they're within an hour from the facility. All they have to do is keep it at room temperature and that's it.

Host: Yeah. That's much easier than the timed evaluation workup for the female.

Dr. Astrid Mondaca: Yes, much easier. Because like the HSG, which is a hysterosalpingogram, has to also be done day 12 to 14.

Host: So, it could actually take a few months for the workup if they end up needing that because they have to time it with their cycle.

Dr. Astrid Mondaca: Correct. And then I have some patients that don't even ovulate, so we have to stimulate the cycle with Provera, which is progesterone.

Host: In order to, again, accommodate those exams.

Dr. Astrid Mondaca: Correct.

Host: Now, you did mention that you do a full physical exam. Are there any other generalized medical conditions that can cause infertility?

Dr. Astrid Mondaca: Well, we want to also look at family history as well. Because if, for example, females in their family have gone into premature ovarian failure, like they've gone through menopause early, you definitely want to look into that. And that's when day 3 labs come in when you're looking at FSH and estradiol. You want the FSH to be less than 10, day 3. And that's what we look for. And there's also other factors as well that we look for any sexually transmitted infections in the past, because chlamydia and gonorrhea can cause infertility issues because they can block those tubes.

Also, any surgeries, let's say they had a C section the first time, or pelvic inflammatory disease that causes scar tissue within the abdomen. That could also cause a blockage in the tubes, and we know that sperm needs to go through the tubes in order to fertilize the egg, which could also be an issue for some females.

Host: It sounds like, you know, you guys do such a thorough workup to really make sure you can find the cause.

Dr. Astrid Mondaca: Yes, we do. And we try not to do unnecessary things either, because like you said, it's time-consuming. Some women don't have that much time, especially women over the age of 40. So, it's really important to try to pinpoint what's going on and get them help as soon as possible.

Host: Absolutely. Now, Dr. Mondaca, when a patient is diagnosed with secondary infertility, what treatment options are available?

Dr. Astrid Mondaca: When somebody is diagnosed with secondary infertility, some OB-GYNs, and not all, are comfortable with treatment options. For example, if it's a patient that has PCOS or is not able to ovulate on her own, we have medicines that could help stimulate those ovaries to get them to ovulate and to conceive that way. There are other options, depending on what's going on, if it is anovulation, which we call where you're not able to ovulate on your own, there are higher chances of conceiving through a specialist who will stimulate those ovaries and sometimes give you what we call a trigger injection. So that an intrauterine insemination where they take the sperm and they kind of weed out all the things they don't need from the sperm and bypass the cervix into the uterus while stimulating those ovaries to give you a higher chance of conceiving on your own. But sometimes with that, you can get multiples. So, we always do counsel our patients about the stimulating drugs because that could be one of the risks that you take.

Another option is what we call IVF, in vitro fertilization. And that's usually done with a specialist, an REI, reproductive endocrine infertility specialist, that we can refer you to if that's the route you need to go because 15% of the time we don't know what the cause of the infertility is. You may not find out why it happened.

Host: So, Dr. Mondaca, when a patient is wanting to conceive or having issues with secondary infertility, when do they see a regular OB-GYN versus asking for that referral to the REI, the reproductive endocrinology and infertility specialist that you mentioned?

Dr. Astrid Mondaca: If it's somebody, let's say they've been trying for a year and they're under the age of 35, or if they're 35 and older and trying for 6 months and unable to conceive, I would always recommend them start with an OB-GYN, because sometimes people don't know about the specialist or which ones to go to. And then, sometimes you need a referral, like the specialist wants you to refer to them.

I'm very realistic with my patients. Let's say time is not on their side. And I don't want to waste time trying to stimulate the ovaries because it's not an ovulation issue and they need to seek help immediately. What I like to do is do the workup, get them the referral to get the semen analysis and where to go to get those labs day 3 and day 21, get an ultrasound just to make sure there's nothing I can do to help them. Let's say there is a polyp inside the uterus, for example, and I could try to remove it before I can get them to see a specialist. Certain things like that, I like to get them started, if you will.

Host: Start the process so that the specialist can then jump in and kind of do their portion. That's fantastic.

Dr. Astrid Mondaca: Yes. Because the more information they have, the better chances of them going over a plan with the couple to see what their options are, or where they want to start, or how they want to go about their infertility journey.

Host: Dr. Mondaca, you have shared so much wonderful information with us. As we wrap up, is there any other tidbits or information that you would like to share with our audience?

Dr. Astrid Mondaca: I know that everybody listening in is probably wondering why we chose this topic, and I got invited as a guest to speak about it, because I suffered from secondary infertility myself. It was really hard on me, actually, being the patient. And I don't know, it's kind of dear to my heart now because at the time, I felt so alone.

Host: It means a lot to us to know that someone as certified as yourself and has actually went through this as well, so it makes it very real that you can connect to the audience like that.

Dr. Astrid Mondaca: It's really put a different perspective on infertility, honestly. So, I do encourage women, you know, to seek help right away. And there are options out there and they're not alone. I just want them to know that. And hopefully, this podcast helps them because I was lucky and fortunate enough that I knew what to do and I got everything started right away. I knew something was wrong. And thankfully, with the help of my colleagues, my REI specialists, they were able to help me, and I was able to conceive my daughter.

Host: Oh, that is such a heartwarming story. I literally got chills. Thank you for sharing that, and congratulations.

Dr. Astrid Mondaca: Thank you so much. Yeah, she's two and she's a handful, but I'm so happy she's here.

Host: She’s your blessing and we are so blessed that you were able to share all of this wonderful information with us. And thank you for opening up about your personal experience. I know that's not easy, but it really does help our audience understand that they're not alone.

Dr. Astrid Mondaca: Yes. And thank you for taking the time and letting me speak about it. It is really nice to get it out there, honestly.

Host: Absolutely. Once again, that was Dr. Astrid Mondaca, a board-certified OB-GYN. Thank you so much for joining us today, Dr. Mondaca.

Dr. Astrid Mondaca: And thank you. Happy to be here.

Host: I'm your host, Dr. Rania Habib, wishing you well. That wraps up this episode of BayCare HealthChat. Head on over to our website at BayCare.org for more information and to get connected with one of our providers. Please remember to subscribe, rate, and review this podcast and all other BayCare podcasts. For more health tips and updates, follow us on all of your social channels. If you found this podcast informative, please share it on your social media and be sure to check out all other interesting podcasts in our library.