Secondary infertility, the inability to conceive and deliver a child after already having delivered one or more children, is more common than you may think. Some doctors believe it is difficult to obtain accurate statistics on just how common it is, because many couples are able to treat themselves effectively or simply do not seek treatment from a doctor. Women often have the misconception that if they delivered a healthy child before, they simply cannot fall into the category of the infertile.

Reasons for secondary infertility are often the same as those found in primary infertility. Dr. Anthony Luciano, the director of the Center for Fertility and Reproductive Endocrinology at New Britain General Hospital in Connecticut, cites the most common causes as semen abnormalities (low count, deformities, poor mobility); ovulatory problems; endometriosis and pelvic adhesions; and uterine abnormalities (fibroids, polyps).

It also can be a matter of timing. Some couples can successfully conceive through a few changes in lifestyle and careful planning. The key is education. To start, Dr. Luciano suggests determining when ovulation occurs by using urine ovulation predictor kits that can be bought over the counter. These kits predict ovulation within 24 to 48 hours. "You must have intercourse the day of and after a positive result," Dr. Luciano says. "It is important that the sperm is present in the reproductive organs when the egg is released, hence intercourse [should occur] within 12 to 36 hours prior to ovulation. It is better to have intercourse too early than too late!"

This has been the plan thus far for Ninotchka Beavers from Dallas, Texas. She and her husband have been trying to conceive their second child for nearly six months. Their first daughter was conceived during the first month of trying and the pregnancy advanced without complications. Beavers thought it would be just as easy when they decided to try for No. 2.

"We've tried an ovulation calculator/calendar," she says. "We tried the 10/20 method, which is making love every other day from cycle day 10 through 20. We've tried a saliva OPK [ovulation predictor kit], which I found difficult to read and stopped using after two weeks. We've tried monitoring cervical mucous in order to detect ovulation. I am currently taking my temperature daily and using the Clear Plan Easy Ovulation Sticks. They are relatively inexpensive. You pay around $20 for five sticks and a pregnancy test."

Megan Millimaki of Katy, Texas, began having problems after the birth of her first child. She had a myomectomy – the removal of a fibroid tumor outside the uterus – and became pregnant. Unfortunately, Millimaki miscarried on Mother's Day. She had a D&C the next day. From that point on, her periods have been very irregular, varying from 21 to 29 days, rarely being the same for two consecutive months. She was, however, still optimistic after the pregnancy loss. "I [was] confident we [would] be able to conceive again after the new year," she says.

Millimaki also purchased the ovulatory predictor stick kits, but found they did not work for her. She then purchased the Clear Plan Fertility Monitor ($189), which was effective in helping them to conceive the following February. In addition to the use of the monitor, Megan's husband "consulted with his doctor because of his asthma and a sciatic nerve problem that causes his lower back and leg to go numb at times," she says. "Although he has no problem obtaining and keeping an erection and ejaculating on his own, he was given a prescription for Viagra to give him slight assistance in relieving the physical and psychological pressures of completing the 'task' on target dates if he wasn't feeling well."

Dr. Luciano recommends a woman seek professional help after four months if she is over 39, after six months if she is between 35 and 39 and after nine to 12 months if she is younger than 35. However, there are times when a couple should not wait, and immediate intervention is needed. "If you have irregular periods, that suggests the lack of ovulation," he says. "Very painful periods and pain with intercourse suggests the presence of endometriosis or other pathology of the reproductive organs. Significant vaginal discharge with burning or discomfort suggests a vaginal infection. For the man, painful ejaculation suggests infection. When a man has a decreased libido or impotence, it suggests a hormonal or testicular problem."

Traci LaRosa of Wahiawa, Hawaii, had no problems conceiving her first child. Her second child was conceived after nine months of trying. After passing that mark while trying to conceive No. 3, she decided they needed to seek a doctor's help. "We went to a doctor that did a bunch of blood work and a semen analysis on my husband," LaRosa says. "It all came back fine. The doctor didn't follow through after that, or order any other tests, so I was a little disappointed. He assumed everything was fine and it would just happen.

"Luckily, we moved and my current doctor ordered more preliminary tests," she says. "When those came back fine, he ordered an HSG (a test where they inject dye into the fallopian tubes and then X-ray to see if there is a blockage). The test showed a block in one tube. He then did laparoscopy surgery. The blockage wasn't as bad as initially thought, so we then began Clomid and the intrauterine insemination when I ovulated. We don't know if it was successful yet."

LaRosa's experience withher first doctor begs the question, What should be expected of a doctor and the first visit to a fertility specialist? First, make sure that the doctor is trained and experienced in dealing with infertility. "The best assurance of this is the completion of a fellowship and certification by the Board of Reproductive Endocrinology and Infertility," Dr. Luciano says. "Also, inquire how much experience the doctor has in treating infertility and what the success rates are for different causes. Most specialists will readily provide the information."

Dr. Luciano believes the first visit should be fairly extensive. "The initial visit should include a complete medical history for both partners and a complete physical exam for at least the female partner," he says. "A vaginal ultrasound is very informative and should be performed at the same time as the pelvic examination. The various potential causes of infertility are discussed. The evaluation and the reasons for the blood test, radiology tests, etc. are explained to the couple at this visit. A general outline of the entire evaluation is described and provided to the couple, preferably in writing. When the couple leaves after their initial visit, they should have a clear understanding of the physiology of conception, the infertility evaluation and the time frame by which the evaluation will be completed."

Patient involvement during treatment is essential. You should research, ask questions and express concerns as soon as they arise. You must also let the doctor know the things with which you are and are not comfortable. If there is any doubt, consider seeking a second opinion.

No matter what the tests find, consider all options. Crystal Irwin of Moreno Valley, Calif., is trying to conceive her third child. Her first two were conceived while on birth control, so she and her husband suspected problems after three months of trying while off birth control. They had been trying since November 1998 and decided to pursue adoption after a miscarriage. They had not previously sought treatment, due to lack of coverage and concerns about the safety of drugs in relation to her family history of cancer.

"We hoped to experience pregnancy together," Irwin says. "That was more our drive for conception than the overwhelming desire for another biological child. It is a factor, just not an overwhelming one. We both love kids and enjoy their company, whether they are related to us or not. So we have discussed adopting older kids. This gives them a home where they will be loved and appreciated and allows us to expand our family. Due to my childhood experiences, I feel I can understand much of what a kid in foster care has been through. I think we, as a family, have a lot to offer a kid who has been through a difficult time."

No matter how long a couple has been trying to conceive, emotional support is essential. Usually, family and friends are the first to come to mind. However, they may not always be able to relate. Seeking a support network of others who are going through the same experiences can help during the tough times. Many doctors can give information on support groups that are in the community or organized through the doctor's office. Preconception.com also has a wealth of support areas, from discussion boards to diaries. Beavers says, "I truly find Preconception.com the most informative. I've found limited information on preconception in other places, but not one site as comprehensive as Preconception.com."