For most people, infertility conjures up the image of a couple without a child. But what about the couple who has borne a child, and now wants to extend their family but find they are unable to do so?

Secondary infertility, is the inability to conceive after one or more successful pregnancies. The medical causes are similar to those of primary infertility, and include sperm problems, tubal factors, endometriosis, and ovulation difficulties. However, there are differences. For one thing, the couple is older, which is why time is at a premium!

Moreover, there are emotional aspects that are unique. The couple experiencing secondary infertility often finds it difficult to gain understanding or sympathy from family, friends and relatives. Since they have one child, most people assume that the couple will have no problem having another. Even other infertile couples offer little sympathy! Patients with primary infertility often resent couples who have a baby, and believe their own pain would disappear if only they too could bear one child. A common remark is, "You have one child, you should be grateful for that." These couples are caught between two worlds, fertile and infertile - and are excluded from both!

Guilt and frustration are common emotional responses. The frustration is borne out of surprise because the couple didn't think it would be difficult to conceive a second time (unless they had difficulty in getting pregnant the first time as well). However, just because they have got pregnant once doesn't make them immune to all the illnesses which can cause infertility - and tubes can get blocked and sperm counts drop as time goes by!

Secondarily infertile couples who had an elective abortion done for the first pregnancy and cannot conceive a second time around have a very hard time coping with their feelings of guilt. They often feel they are being punished for their sin of rejecting the child when they had it.

Couples with a child at home may also feel guilty. This arises because they catch themselves feeling that their one child isn't good enough for them; and also for their inability to provide their child with a sibling.

The child of a secondarily infertile couple may also bring unwitting pressure on his parents by asking when he 'll have a baby brother or sister. This is especially difficult when the child is being asked by his friends why he doesn't have a baby brother or sister and then begs his parents for a baby.

Parents may become very overprotective, fearing that something may happen to the one child they do have. They may also push pin all their hopes on their one child, and may push him to be a high achiever.

Many couples with secondary subfertility choose never to take medical treatment; often, this is because they are unsure about whether they do have a problem - and they keep on trying, hoping to hit the jackpot once again (after all, if they could do it once, why can't they do it again?)

What are the chances of a couple with secondary subfertility conceiving with medical treatment? While this would depend on the individual's problem, their chances are really about the same as a couple with primary subfertility. While they have the benefit of having "proven" their fertility once, they usually have the handicap of an increased age against them.

If the couple chooses to seek medical intervention, they also must decide what to tell their child about medical procedures. The presence of a child at home can make coping with the demands of infertility treatment much more difficult!

The financial burden of taking treatment can also add to the emotional burden of the couple and they may wonder if they shouldn't be spending the money on the child they already have rather than pursuing the hope of expanding their family.

Adoption can be a choice for some of these couples - but it's often more complicated because they worry about the possibility of "favoritism" ; and may also feel that it is unfair to their biological child to bring an adopted child into the family.

Coming to terms with secondary infertility is no easier than coming to terms with primary infertility - and it's important that the family of the secondarily infertile couple share their feelings together and maintain a positive attitude.