Secondary infertility: when a second child doesn’t come

“Mummy, why don’t I have a little brother?”

The question comes from the back seat of the car, between two traffic lights, in that completely serious tone only four-year-olds have. The mother at the wheel says something — “we’ll see”, “maybe one day” — and keeps looking straight ahead. Later, at home, she stands under the shower for a long time. Behind her are two years of trying, a pile of tests, and one day every month when she knows it hasn’t worked this time either. Almost nobody knows. Because she has a child, after all. Because it worked once before.

This piece is about secondary infertility — about what it is like to want a second (or third) child who doesn’t come. About a grief that the people around you rarely grant the right to exist, about guilt towards the child who is already here, and about what happens to a couple in the meantime. You won’t find medical answers here: what is happening in the body and what can be done are questions for a gynaecologist or a fertility clinic. This is about what remains once you close the door of the consulting room.

What secondary infertility is — and how common it is

The World Health Organization defines infertility as a couple not achieving pregnancy after twelve months of regular unprotected intercourse. We speak of secondary infertility when a woman has already been pregnant or has already given birth, but a new pregnancy or birth does not follow. The exact cause differs from couple to couple — sometimes it is found, but often it isn’t.

Most people think secondary infertility is rare. It isn’t. When researchers working with the World Health Organization reviewed 277 national surveys from almost every country in the world, they estimated that in 2010, 10.5% of women who had already given birth and wanted another child were unable to have one. Among women wanting their first child, the proportion was considerably lower. In that analysis, then, secondary infertility was more common than primary — it is simply far less visible.

That invisibility matters. Because we at least roughly know what primary infertility is like, people often show some consideration around it. With secondary infertility something else happens: because a child exists, people take it as proof that nothing is wrong. Or as the reason why it shouldn’t hurt.

“But you already have one”

This is the sentence people with secondary infertility hear most often. Sometimes a mother-in-law says it, sometimes a friend, sometimes a doctor, sometimes the person says it to themselves. It is meant as comfort. It works as a prohibition: a prohibition on being sad.

The American researcher Kenneth Doka coined the term disenfranchised grief for this kind of sorrow — grief for a loss that society does not see or does not take seriously. I wrote about it at greater length in The grief nobody acknowledges: miscarriage, divorce, losing a job. Secondary infertility belongs here almost by definition. There is no funeral, no date, no object you could put away in a box. There is a child who isn’t there — and a family that already had its shape in your mind.

When grief isn’t acknowledged, it doesn’t disappear. It goes underground and often returns in another form: as irritability, tiredness, quiet anger around pregnant friends, or as the feeling that you are ungrateful. That last one is particularly insidious with secondary infertility. People often say “I know I should be happy” — and with that sentence they close the door on everything they feel. What happens inside a person after a loss is briefly explained in the knowledge base under grieving.

Gratitude and grief do not cancel each other out. You can be immensely grateful for the child you have and at the same time grieve for the child who isn’t there. These are not two sides of a scale, where one has to outweigh the other. They are two truths living in the same body.

Between two worlds

One of the loneliest sides of secondary infertility is that you don’t fully belong anywhere.

Your everyday life is the life of a parent: nursery, the playground, birthday parties, conversations about sleep and tantrums. And that very world is full of pregnancies and second children. The mums at nursery talk about what it will be like when the “little sister” arrives. At a third birthday party there are three bumps. Each of those moments is a small blow — and because they happen in the middle of your ordinary life, you can’t avoid them the way people without children can simply skip a celebration. How to get through moments like these is the subject of a piece in the same series, When everyone around you is pregnant: holidays, christenings and birthdays.

But if you look for a community of people with infertility — a forum, a group, a waiting room — you may run into a different kind of awkwardness. There, you are the one who already has a child. Some will accept you without hesitation. Others will feel a pain around you that you never meant to cause, and you will notice it. Many people in this position start hiding their child in such spaces or staying quiet about them — which is yet another way of not being fully seen.

This in-between place is not a personal failing. It is the result of there being no space made for your situation.

Guilt towards the child who is already here

With secondary infertility, guilt often splits in two directions at once.

On one side is the guilt of not being able to “give” your child a sibling. Many parents carry the belief that a child without a brother or sister misses out — that they will be lonely, spoilt, or one day left to care for ageing parents alone. When the child asks for a baby brother themselves, that belief digs in even deeper.

On the other side is the guilt that treatment, waiting and grief are pulling you away from the child you have. That at the playground your mind is elsewhere. That their laughter sometimes hurts, because it reminds you of the one who isn’t there. That you are worn out by appointments and have no patience. That you cried on their birthday, and not from happiness.

Both kinds of guilt are understandable, and both are often unfair to you. Guilt is an emotion meant to warn us that we have wronged someone. Here there is no wrong — there is a circumstance you didn’t choose. You can read more about how guilt works, and when you don’t have to believe it, in the knowledge base under guilt.

Research can also help ease the guilt that your child “needs” a sibling. In a large review of studies on only children, the American psychologists Toni Falbo and Denise Polit found that only children do not differ substantially from children with siblings in personality, adjustment or peer relationships — on some measures, such as achievement, they even did slightly better. A child without a sibling, then, is not a child who is missing something. They are a child in a different kind of family.

When your first child asks

Children sense more than we give them credit for. Even if they know nothing about tests and treatment, they pick up that Mum is often sad, that Dad is quieter, that conversations stop when they walk into the room. If they have no explanation for this, they often make one up — and children’s explanations tend to put the child at the centre: “Mummy is sad because of me.”

You don’t need to explain the medical details. But you can tell even a very young child a simple truth: “Daddy and I would love another baby, but it isn’t happening. That’s why I’m sometimes sad. It isn’t because of you, and it isn’t something you have to fix.” An older child can be told more if they ask. What matters is that the child isn’t given the job of comforting you, and doesn’t become a substitute for the answer you don’t have.

If your child keeps asking for a sibling, you don’t have to promise them one, and you don’t have to answer “never”. You can acknowledge the wish — “I know you’d like a little brother; we would love one too” — and stay with their disappointment without trying to fix it. That way you teach them something worth more than a sibling: that it is possible to live with an unfulfilled wish, and that grown-ups don’t fall apart around it.

What happens to the couple

Secondary infertility puts a strain on a couple much as primary infertility does — how infertility changes a relationship is the subject of Infertility as a test for a couple: what happens to the relationship. But it has some features of its own.

It often happens that the two partners don’t feel the wish for a second child equally strongly. One feels the family is “unfinished”; the other might be content with one child. As long as things came easily, the difference didn’t matter. When every next step requires tests, money, time and hope, it becomes a question: how much is this wish allowed to cost? And who gets to decide?

On top of that, the couple is dealing with parenthood and infertility at the same time. There is no time to withdraw and grieve — in the morning the child needs dressing, in the afternoon taking to training, in the evening a bedtime story. Many couples switch into survival mode: they stay a good parenting team but stop being a couple. When I ask someone in this period when the two of them last talked about anything other than the child or treatment, they often can’t remember.

They may also grieve differently. One needs to talk, the other needs silence and work. One talks to a friend about it, the other wouldn’t say a word to anyone. A difference in how you grieve is not a sign that one of you doesn’t care — I wrote about this in Grieving as a couple: why you grieve differently and how it need not break you.

Here is how a conversation many couples will recognise might sound (composite, not a real person):

“You’re on your phone all evening again, reading those forums.”
“Because you won’t talk about it. I have to talk somewhere.”
“I won’t because every conversation ends the same way. We have Lana. I’m happy.”
“So am I. But that doesn’t mean it doesn’t hurt.”
“…I don’t know what to say when you put it like that.”
“You don’t have to say anything. Just don’t tell me again that I ought to be content.”

This conversation isn’t an argument about a child. It is an argument about whether grief is allowed. When one says “I’m happy”, the other doesn’t hear a report on how he feels, but a verdict: you should be too. But when someone says what they don’t need — “just don’t tell me again that I ought to be content” — a space opens up in which the two of them can meet.

Comparison and envy

Envy is one of the most shameful emotions in secondary infertility. Because you have a child, it feels as if you have no right to envy anyone anything. And yet it happens: towards a sister who got pregnant without planning to, a colleague showing her scan, a family with two children on the next bench.

Envy is not proof that you are a bad person. It is a sign that you want something very much and that it has been taken from you. The knowledge base describes envy as an emotion that points to an unmet need of your own — more under envy. If you take it as information rather than an accusation, it becomes less toxic.

What can help is the difference between what you hear and what lies underneath. The table below is not a collection of correct answers — it is a help in translating the sentences that wound into what you actually needed.

Exercise: two truths on one page

This exercise is for the moments when it feels as though you have to choose between gratitude and grief. Take fifteen minutes, a sheet of paper and a pen. You can do it alone or with your partner.

1. Divide the page into two halves. On the left write “What I have”, on the right “What I miss”. You are not looking for balance — the two sides can be different lengths.
2. Fill in the left side first. Be specific: not “a healthy child” but “the way she wakes up in the morning and tells me what she dreamt”. Three or four things are enough.
3. Then fill in the right side. Just as specifically: “to see the older one leaning over a baby”, “to be four at the table”, “to live through first steps once more”. Let yourself write what you wouldn’t say out loud, too.
4. Read both sides and at the bottom write one sentence that joins them with “and”, not “but”. For example: “I have a child I love, and I grieve for the child who isn’t here.” Notice how differently it lands in your body than “but”.
5. Decide who you will say this sentence to. Your partner, a friend, a sister — someone who will hear it without correcting you. If there is no one like that, that is important information in itself.

The exercise won’t make the grief go away. But it helps grief stop being a secret you carry alone, and helps gratitude stop being a weapon you use to push it down.

Where this view falls short

I want to be honest about the limits of what I have written, too.

First: not every wish for a second child is a grief that needs working through. For some people, accepting one child is a fairly peaceful decision that doesn’t leave a deep wound, and that is just as valid. You don’t have to suffer for your experience to be real. If the people around you — or an article — imply that you ought to be more upset than you are, you don’t have to believe them.

Second: this piece is no substitute for medical care. When and how to seek help with conceiving, which tests make sense and what treatment options exist are questions for a gynaecologist or a fertility clinic. Psychological support can run alongside treatment, not instead of it.

Third: sometimes grief grows into something that needs more than conversation. If for several weeks you feel empty almost every day, are losing interest in things you used to enjoy, are sleeping badly, or feel that everyone would be better off without you, see your GP or a psychiatrist. If thoughts of death are strong, in Slovenia you can call the mental health crisis line on 01 520 99 00 (every day from 7 pm to 7 am) or the Samaritans helpline on 116 123 (24 hours a day), and in an emergency 112.

And fourth: the gratitude I have defended in this piece as something allowed to exist alongside grief is not a cure. You don’t have to “practise” it so that it hurts less. If you feel it, good. If you don’t feel it right now, that doesn’t make you a bad parent.

How therapy can help

People with secondary infertility often come to therapy late — if at all. Because they feel their problem “isn’t big enough”. Because they have a child and ought to be happy. But therapy isn’t a prize for the greatest distress. It is a place where what has no room outside can be heard too.

Some of the themes I often encounter in this work:

• Grieving the picture of a family. Each of us carries an idea of what our family should look like — often taken from our own childhood. When that idea isn’t realised, it is a loss worth putting into words. This is also the subject of The loss of a plan: when life doesn’t turn out the way you thought.
• Agreement within the couple. How much time, money and strength the couple is prepared to invest, when enough is enough, and how to stay together if you see it differently.
• Parenting in a time of grief. How to be present with your child without loading your pain onto them — and how to forgive yourself the days when you can’t.
• A look into the past. It often turns out that the wish for “at least two children” has roots in your own family: in a sibling who was your only support, or in the loneliness of being an only child. Once that becomes clear, the decision is freer.

In relational family therapy, in which I am training, we always look at distress through relationships as well — between partners, between parents and child, and across generations. If you are curious how expectations of what a family should be have been passed down in yours, a longer session drawing a genogram, A Look into the Past, can be a good way in. I am happy to work in English too. I wrote about how parenthood changes your identity — even when it doesn’t unfold the way you hoped — in Parenthood as a transition: who am I now that I am a mother or a father?

A shorter explanation of how infertility affects psychological wellbeing is in the knowledge base under infertility and distress.

What to remember

• Secondary infertility is common — in a World Health Organization analysis even more common than primary infertility — it is just less visible.
• “But you already have one” is not comfort but a ban on grief. Gratitude and grief can exist at the same time.
• Guilt towards your first child is understandable but often unfair: research does not show that only children lose out.
• You can tell your child a simple truth without giving them the job of comforting you.
• Medical questions belong with a gynaecologist; if grief turns into lasting emptiness, see a doctor or psychiatrist.