The Infertility Therapist

Not quite free to be you and me: Infertility treatment and the recogntion of our limitations

2012-02-17T16:17:00.000-08:00

I have come to the conclusion that it is all Marlo Thomas' fault.

As a child growing up in the 1970's, I was raised on a steady diet of "Free to Be You and Me" encouragement--women, it seemed, could have it all. They could be whatever they wanted--being professionally successful and a mother was no problem. There were no limits. All a girl had to do was to do her best, and work as hard as she could. This message seems to be permanently woven into every fiber of my being. Even though I now know this is not always true, it seems like I constantly default back to this belief. I somehow manage to forget that I, like us all, have limitations, some insurmountable. Every time in my life it again proven that hard work can't solve everything, it stings just as much. Over, and over, it is an unpleasant, and unwelcome, surprise.

Now I understand what Ms. Thomas was trying to accomplish. For much of our history, women were discriminated against, and discouraged from entering the professional world. I am enormously grateful that my generation of women received the encouragement and opportunities that we have. And of course, I recognize much of the wisdom of Ms. Thomas' teachings. In almost all areas of life, attempting to solve problems through effort and hard work is a very successful strategy. I also believe that without trying, we may never know what we can accomplish.

My problem with the "free to be mentality" is this--if for some reason you couldn't do whatever you wanted, then logically you could conclude that you hadn't worked hard enough or tried your best. A problem that couldn't be solved with hard work didn't exist in this scenario. If there were no barriers to your success, there could be no other explanations for your failures. It is all on you. I'm sure this logical corollary was completely unintended by Ms. Thomas.

Despite this, whenn it comes to infertility, this type of thinking can be extremely problematic. IInfertility is not a problem that can usually be solved by effort and hard work alone. Physical variables, and frankly, luck, seem to be the trump card in many cases. Thus, despite all the efforts made to fix the problem, it is often experienced psychologically as a profound personal failure. Lest this just be my issue, nearly every infertility client with whom I have ever worked has expressed strong concerns that their infertility was somehow their fault, and that the reason that they couldn't have a baby was because they had done, or were doing, something wrong. In all of these cases, the problems, whether they could be fully identified or not, lay outside of the person's sphere of control.

In my case, infertility turned out to be more than the inability to have a child, but realization that my philosophy of living was fundamentally flawed. I suppose that's a good thing, because it's more realistic. In learning to accept the limitations of our bodies when it comes to creating a baby, we learn that not all things are possible after all. This is a painful but important realization, for there will be other aspects of life in which we will also be unable to achieve our goals.

On the other hand, my infertility would have been much easier for me to cope with if I had considered the possibility that there were going to be many things in life I wasn't going to have the ability to do, and that was how it was for everyone. It didn't mean I was a bad person, flawed, cursed, or lazy. It was just unfortunate that my talents didn't lie in this particular direction. Based on my clinical experience, I suspect this is the same for others as well.

As for hard work, I still believe in its value. When I recently discussed this issue with my mother (the one who relentlessly played the "Free to Be" album, and in many other ways promoted the omnipotence of hard work during my childhood), she was unmoved. "Look," she said, "You have lots of problems with infertility. And yet you still have children. You worked hard to make it happen. Marlo Thomas was right." And I really do see her point, especially if you look at the big picture.

But like most of us, during infertility treatment, I couldn't look at the big picture, mostly because it wasn't drawn yet. So all I saw were a series of physical failures, despite maximum effort and worry on my part. It took a while to realize that hard work wasn't going to solve the problem alone. During that time, my self-esteem was in tatters. It has taken years to reorganize my way of thinking, and to come to terms with my physical, intellectual, and emotional limitations.

If you are reading this, I just hope you can learn all of this much faster than I did. While we all can and should try to achieve our goals, we must forgive ourselves, if through no fault of our own, we cannot. In that way, I think we can be most free to truly be ourselves.

Misperceptions, Misinformation, and Infertility Treatment: Psychological Implications

2012-02-02T14:12:00.000-08:00

Last week, as part of his campaign in the Republican primary in Florida, Newt Gingrich stated that if he were president, he would appoint a commission to investigate IVF clinics, as embryos (and to his way of thinking, life) are created there. There are probably some political machinations and implications of this pledge that I don't fully understand. However, it did get me thinking--what exactly does Mr. Gingrich think that such an investigation is going to find? Somehow, Mr. Gingrich seems to believe that embryos are being developed for the wrong reasons or capriciously destroyed or mistreated. The irony here, I think, is that no one values the sanctity of human life more than those who are infertile. People going through the physical, emotional, and financial hardships of IVF value their embryos, and the children they might possibly create, above anything else in the world.

But Mr. Gingrich is not alone in his misperceptions of and mistrust in infertility treatment. A day after his announcement, I found myself explaining to a group of other mothers at a preschool fundraiser that the Octomom was not the norm in infertility treatment. One woman thought that in IVF, the patient was forced to transfer back all the embryos that had been produced in their cycle, and thus higher-order multiple births were the norm. A long discussion of embryo cryopreservation and medical ethics ensued. The mothers seem surprised to learn that the Octomom's doctor was investigated on ethics charges, that most reproductive endocrinologists try to avoid multiple births, and the field is moving towards single embryo transfer. All they knew about IVF came from sensationalist headlines describing the exception to the rule.

These views are often furthered by inaccurate portrayals of infertility treatment and IVF in movies and on television. I am often stunned by the countless examples of medical inaccuracy of television shows when it comes to reproductive issues. For instance, the show Private Practice, which frequently features themes of infertility and infertility treatment, has on multiple occasions depicted infertility treatment incorrectly. My favorite instance involved a doctor using a microscope in the room with a patient to fertilize an just-retrieved egg, only to immediately transfer it back and pronounce her successfully pregnant, much to the joy of all in the room. Anyone who has ever actually done IVF knows its just not that simple! It amazes me that television shows wouldn't hire a consultant to make sure they were getting their facts straight.

In addition to getting the facts wrong, television shows and the movies often portray infertility treatment in a more sinister light, pulling from the extreme situations in the news that get all the attention. Thus, the general public tends to develop a skewed sense of infertility treatment. For instance, a recent episode of CSI Miami focused on the murder of a sperm donor who fathered over 100 children, all of whom became suspects in the criminal investigation. Although there have been cases where one sperm donor has produced a high number of offspring, I suspect again this is much more the exception than the norm. However, if this is the major exposure that most people have to the idea of sperm donation, they will tend to look at it in a more negative light. I suppose stories about wholesome people with a medical struggle doing the best they can to have a family just don't get the ratings.

My concern about the negative portrayals of infertility treatment in politics and the media is that it perpetuates the already preexisting stigma surrounding infertility. For individuals undergoing infertility treatment, it is exhausting and demoralizing to continually have to fight stereotypes of their treatment. The effort involved in managing the reactions of others colors every social interaction involving treatment and infertility, and takes a lot of energy. When, as in infertility treatment, energy is in short supply, it seems a shame to have to use it to protect ourselves from judgements of others based on misinformation. Even though I've been around infertility for a long time, and have many opportunities to process my feelings regarding it, it still felt burdensome to set the preschool moms straight about the Octomom situation.

In addition, suggestions like Mr. Gingrich's that some secret evil is going on in infertility clinics can cause individuals in treatment to question themselves unnecessarily--although they can't see how they are doing something wrong. Almost all of the clients I work with have carefully considered, without any prompting from me, how their infertility treatment plan fits in with their sense of morality and ethics. IVF isn't the kind of thing that people enter into lightly. Thus, when someone in a prominent public position intimates that what they are doing is suspect, without specific information to back it up, they spend a lot of energy and time questioning themselves. If they are already feeling shame about being infertile, they may be especially sensitive about such suggestions. This adds to the pain of an already difficult situation, and is, as far as I can tell, completely unnecessary.

Relational Infertility: When partners don't agree

2012-01-26T18:23:00.000-08:00

I am part of an email listserv for the Mental Health Professional Group of the American Society for Reproductive Medine, in which mental health professionals discuss psychological issues surrounding infertility. This week there was a fascinating discussion of what do when there is in impasse in couple therapy, in which one member of the couple wants to pursue having a child, but the other member does not. Perhaps there is a disagreement about what method of family building to use--one person is against using donor gametes, or adoption. Other times, the conflict centers around whether or not to have a child, or another child, at all. On the listserv, there were different suggestions about how to be helpful in this situation, but all the clinicians agreed that these are usually very difficult and painful situations for the couple involved.

I have come to realize that there are actually many different types of infertility. Of course, there is your garden-variety medical infertility, which in some ways, though emotionally painful, is a bit more clear cut. There is also situational infertility, in which an individual or couple cannot pursue having a family because of their circumstances, for example, if a family member develops a serious illness, or a financial crisis occurs. But when the members of a couple seriously disagree about if and how to have a child, then relational infertility occurs. This type of infertility often coexists with medical and situational infertility.

In many ways, relational infertility can be the most painful type of infertility of all. With medical or situational infertility, the causes are usually out of anyone's control. But when the family-building impasse is caused by a choice, the feeling is that things could be different--if only the other person would change their mind. In a couple, such a conflict can be very difficult on a relationship. Both partners have to face the dilemma of either having some serious regrets and resentments for the road not traveled, or conversely ending an important relationship. This is because it is often very hard to create a compromise in these situations--you can't have or not have a baby half-way.

One of the things that struck me about the discussion on the listserv is that my colleagues, like myself, didn't have any easy answers for dealing with such a dilemma. I suspect that this is because there simply isn't one. Having, or not having, children is one of the most important life decisions a person can make. At times, the importance of these desires can override the desire for being in the relationship.

However, if you find yourself in this type of conflict with your partner, there are some steps you can take to try to resolve the situation. The most important thing you can do is try to listen to your partner very carefully. Even if you don't agree with their perspective, it is important to try and understand it. Try to put yourself in your partner's shoes and see things from their point of view. If you can develop empathy for what your partner is feeling, you may be able to become less rigid in your own position, and a solution may be possible.

In cases of relational infertility, it is also important to consider whether or not other underlying issues and conflicts you are experiencing as a couple are coloring your feelings regarding having a family. For instance, if there are problems with emotional closeness and support in the relationship, one of the partners may be more hesitant to add on the additional work and stress of having a child. Certainly, if one of the partners is already having doubts about continuing the relationship, he or she may not want to make the additional commitment of having a child together.

In addition, at times an individual's psychological issues can contribute to an relational infertility impasse. For example, one couple with whom I worked was locked in conflict about whether to continue fertility treatments--the wife wanted to stop, whereas the husband desperately wanted to continue to try for a baby. Over time, it became clear that the wife had deep-seated doubts about her own ability to parent successfully. These doubts were rooted in her experiences growing up with her own parents. As she became more aware of these issues, and her husband developed a greater understanding and empathy for her feelings, the couple was better able to decide together what their future would hold.

With relational infertility, the stakes are very high. I think it must be very hard to be the person who kept a partner from his or her dream of having a child. Conversely, it must also be extremely difficult to feel that one's partner is resentful about parenting, or not fully committed to a child. Ending a relationship of long-standing can also be extremely painful. Thus, if you find yourself in this situation, think carefully before you act or make your final decision. Seeking couples therapy with a therapist knowledgeable about infertility would be very helpful in negotiating such an important and life-changing decision.

Infertility treatment and the "Type A" personality

2012-01-13T16:41:00.000-08:00

I can only imagine what must be like to be able to get pregnant and have children easily, without much effort. The analogy that comes to mind is the ease with which I taught myself to read, at age three. Watching public television along with my older brother, I learned the letters, their sounds, and how to put them together very quickly. I had my own library card by the time I was in preschool. Reading never felt like work--it was just something I did, and I took it for granted that I could read whatever I wanted. I had no idea that this was an exceptional experience, so I couldn't understand, and was probably insensitive to, other children to whom reading didn't come quite so easily.

Of course, while reading was my strength, other academic struggles presented themselves. My poor visual-spatial skills have created constant fodder for jokes for my friends and family. Math, physics, and chemistry did not come naturally. However, I was still able to achieve good grades in these subjects in school by working hard and pushing myself.

Society seemed to support my view that hard work was the only necessary ingredient for success. After all, I learned that watching public television too. In high school, I once remarked to my social studies teacher that a person could do whatever they wanted to in life as long as they worked hard enough. A wise man, he sighed, took off his glasses, and told me that was completely untrue. I argued with him, but he simply insisted--a person cannot do whatever they want just by working hard, as different people have different abilities, and there is also the involvement of luck. At the time, I felt he was being negative and discouraging, and I did not believe him.

Well, I believe him now.

Like almost everyone, I assumed that when I wanted to get pregnant, it would happen according to my schedule and my timeframe. I couldn't fathom that it might not happen when I wanted it to, much less at all--and if so, there might be very little I could do about it.

In the early stages of infertility treatment, I clung to my approach of working hard in order to achieve my goal. When treatment started going badly, I resolved to fight harder, to do more, and to keep pushing myself. I felt that if I just tried hard enough, I would get pregnant.

When it finally began to dawn on me that no matter how hard I tried, I couldn't overcome certain biological problems, it caused a great deal of emotional turmoil. Not only was I very upset about my infertility; my entire world-view had been shattered.

I know that my story is far from unique because I hear it from my clients every day. In so many cases, infertility is the first real life stumbling block that cannot be overcome by hard work. Like me, my clients also must grapple with their grief and anger about infertility in the midst of developing a new approach to solving problems.

If you are reading this blog, chances are that you are also a hard-working, high-achieving sort of person yourself. If you too are struggling with the fact that your typical life strategies aren't working with your infertility treatment, know that you are definitely not alone.

It's important to realize that however hard you work at your infertility treatment, it will not be the deciding factor in whether or not is successful--that ultimately, success is left in the hands of biology, chance, and perhaps fate. By acknowledging this, you can let yourself off the hook a bit, and see that your don't need to work as hard as you have, perhaps exhausting or depleting yourself in the process.

On the other hand, it's important not to stop working hard altogether. Although hard work cannot ensure that treatment is successful, it can give you the best opportunity you can have to get pregnant. By making sure you understand your diagnosis and treatment options, and by following your treatment protocols to the letter, you can at least ensure that you've given treatment the best try possible. That's important later on--you don't want to feel that you have regrets that you could have done more.

In the end, it's like so many things--a balancing act. We must work hard enough to make sure we get the best treatment possible, but then we have to acknowledge that there is a limit to what our hard work can achieve. Once we've done everything we can do to further treatment, then we should rest, and try to focus on other areas of our life. This, of course, is easier said than done. But by recognizing that hard work alone doesn't cure infertility (or many other problems, for that matter) we can have more energy to devote to other aspects of our lives, thus making infertility treatment more bearable.

Not-normal is the new normal: Infertility in perspective

2012-01-06T10:09:00.000-08:00

I apologize for not posting as much as I would have liked to in the past several weeks. I've been in a sleep-deprived haze, and had difficulty even thinking in coherent sentences--much less writing them. Things are better now, thankfully, as I am back at work again.

During my break, I've had another opportunity to think about my own infertility and what it has meant in my life. For me, the bottom line is this--infertility was a real deviation from the "normal" life I had envisioned for myself. Like everyone who experiences infertility, I was forced to give up my dreams and expectations about how I would have a family. This was difficult and painful in and of itself, but on top of this, I had to work extremely hard in infertility treatment and in our adoption. After all, nobody makes you get IVF, or adopt--it is a choice, and you must make the process happen. As we all know, these processes are difficult, time-consuming, and sometimes heartbreaking.

Even after I had children, I still struggled with not feeling "normal", and a bit envious of others who were able to take the typical path to parenthood. My adopted daughter, fine now, initially had some health issues that took quite a bit of time to resolve. In my pregnancies, my body, ever uncooperative in the reproductive arena, continued with its contrary ways. However, as time has passed, although I still don't feel "normal", I'm around enough parents, kids, and families to realize that pretty much every one of them has some sort of issue or problem that makes them "not-normal" also. I mention this because when I was undergoing infertility treatment, it was so painful for me to be around babies, kids, and their hangers-on that I didn't get close enough to see the details of the situation. I imagined that everyone else was having a perfect life--certainly a better life than me. Many of my clients have echoed similar sentiments.

Once I started to let go of my expectations of "normalcy", everything started to seem clearer. It was, emotionally speaking, a much less complicated task to just do what I needed to do in my particular situation to have a family. I guess if I had to do it all over again, I wish I would have let go of these worries about being normal much earlier in the process than I did. I think I could have saved myself a lot of anguish, and had more energy left for the formidable tasks that were at hand.

If you also find yourself feeling bad because your situation is not "normal", I hope you can learn from my mistakes, and try to move past this worry, because I don't really believe there is a "normal" way to have a family. There are just different ways to have a family, and they all have the potential to be wonderful and problematic, all at the same time. Try to keep in mind that the fertile world has its share of problems too, and that although you must take a different path, it is not a lesser one.

Also, I'd like to wish everyone the best of luck with all of their adventures in the New Year. If you have any questions, or suggestions of topics you'd like me to address, I'd love to hear them! Please don't hesitate to comment or send me an e-mail at lisarouff@gmail.com.

Infertility and the myth of the reparative experience

2011-11-21T16:15:00.000-08:00

A common theme in psychotherapy is the wish for a reparative experience, or an experience that in some way, makes up for a prior bad experience. Unfortunately, as much as reparative experiences seem like a good idea, the quest for them is actually the cause of much human misery--for in many situations, repair is impossible. For example, if a woman grew up with a parent who was distant and uninvolved, she may find herself romantically attracted to men who are similarly distant and uninvolved. She is motivated by the unconscious idea that if she could just get this man to love her and pay attention to her, it would somehow make up for the fact that her father did not. Of course, we all know how this story goes. Too often, the new romantic interest is psychologically incapable of being emotionally close, and thus the cycle continues. Further, once the woman realizes that she has been, yet again, rejected. she is retraumatized. She then becomes even more invested in the struggle to get a distant and uninvolved man to change.

The same dynamics that can make the struggle for a reparative experience so compelling in terms of relationships also hold true for infertility. In trying to overcome our infertility, we are sometimes not just building a family; we are also attempting to somehow repair the emotional damage done by infertility. I often hear patients tell me that if only they could get pregnant, everything in their life would be fine. And yet, although things are usually indeed better, pregnancy and parenting bring about their own set of stresses and problems.

My own recent experiences have been a case in point. As I have mentioned in prior posts, I was recently pregnant and had a baby boy in October--the result of a final cycle with our one remaining frozen embryo. Throughout the pregnancy, I found myself worried that I would have to have another C-section. I wanted to have a vaginal delivery for a variety of medical reasons, but also because I wanted to feel like I was "normal" in the reproductive sense, at least for once in my life. When it became clear that a C-section was again inevitable, I briefly became depressed. I realized that I too was longing for a reparative experience. Instead, I was forced to accept that my reproductive system was yet again not functioning normally. Since this was definitely my last cycle and my last baby, my chances for a reparative experience were at an end.

However, regardless of the nature of my delivery, nothing can really fix the emotional scars from my experiences with infertility. Despite the fact that I wish it were otherwise, I must accept that for me, having a baby is like driving a very old car from New York to California. The car can only goes 20 miles per hour, and if you don't want it to explode, you have to pull over and add oil to the engine every five miles. Sure, you will eventually get to California...but it will take you a lot longer to get there, cost more money, and you are going to be pretty darn tired once you arrive. And trust me, although that experience is not easy, I know I am lucky to have a car at all.

In the end, we must learn to accept our losses. If we don't, we will find our energy depleted by our efforts to fix what can't be repaired. Even when we are able to overcome our infertility and have a family, we are still likely to have negative feelings about our infertility experience. The good news is that if we can devote our energies to other, more fruitful, endeavors, instead of trying in vain to undo our painful experiences, we can have a much richer, rewarding life. This weekend, I ran into an acquaintance who recently completed her first marathon, which to me seems a very impressive task. At first I thought to myself that I'd never be able to run a marathon, but then I realized that in terms of my infertility, I've been running my own type of marathon for the last decade or so. I think that running an actual marathon, although difficult, may be easier than infertility treatment. Now that I've dealt more deeply with my feelings of loss and sadness regarding my infertility, perhaps I'll have more energy to run my current "marathon"--parenting an infant, preschooler, and tween on very little sleep! And when things settle down, maybe I'll be inspired to run my own kind of marathon, although I doubt it will be the actual kind.

For all of us struggling with infertility, it is important to take a moment to consider if we are on a quest for a reparative experience, even in a subtle fashion. By dealing more directly with our feelings of loss, we may be able to free up energy we can use to create our families, or enrich our lives and relationships in other ways.

My top ten tips for dealing with infertility

2011-10-11T14:48:00.000-07:00

I've been in the infertility world, both personally and professionally, for a long time now. Over this time, I have witnessed some strategies for dealing with infertility which seemed to consistently move things in a positive direction. I thought it might be useful to summarize these strategies for those who may be just embarking on their infertility journey, or who are ensconced in the middle of their struggle.Of course, like most retrospectively formed lists of advice, this is more of a "do what I say, not what I do" type of exercise! My hope is that by sharing these strategies, I can help someone avoid some of the pitfalls I experienced. After all, we all don't always have to learn everything the hard way!

1. Take the outlook that infertility isn't personal. It is a medical condition, plain and simple.

It eludes me how a much controversy exists about whether or not infertility should be considered a medical problem. I guess I can understand why an insurance company executive would wish to avoid this truth. However, I am continually flabbergasted by how many people seem to believe that there is some moral judgement involved. If you are of reproductive age and you can't conceive a child, then it is obvious that something physical is wrong!

2. Realize that yes, this happened to you, and that it is totally unfair.However, if you spend too much time thinking about this, it might drive you a little crazy.

Infertility almost always comes as a bit of a shock, and it is natural to feel cheated when others can conceive easily. It is one of life's mysteries as to why this happens. My best advice is just to try and accept this as a mystery--trying to figure out why unfair things happen usually isn't successful, and it just makes us feel bad.

3. Don't always try to be positive.

Many people feel that if they don't always maintain a positive attitude, they will somehow be inviting bad energy, luck, or events into their lives. However, this simply isn't a realistic expectation. Some situations, by their nature, are just hard, sad, and painful. I feel it is more important to allow yourself the freedom to feel whatever emotions you are having. If you work to express them in a productive way, your feelings will lessen in intensity, and you will be able to move forward.

4. Educate yourself as much as possible about your diagnosis, prognosis, and treatment options.

Although it can be complicated and time-consuming, it is very helpful to know as much as you can about the medical conditions with which you are struggling. This is very helpful in terms of making treatment decisions. In addition, this knowledge can also help you gain a better emotional understanding of your situation, and can also provide emotional closure should you need to move on to other family building options.

5. Don't expect anyone else to care about your infertility problems as much as you and your partner do.

Your medical treatment team, although they may be dedicated to your case, has a lot of other patients and issues with which to cope. You cannot rely on them to be on top of every detail of your treatment--you have to do this for yourself. Also, remember that even though your friends and family care about what is happening to you, they have their own lives and issues. Sometimes, you may need to remind them about what is happening or what help you may need from them.

6. Learn from your painful experiences and mistakes.

Infertility is complicated, and there will be times when you may make the wrong decision, or end up having regrets. This is inevitable. The important thing is to not be afraid to use these experiences to change your problem solving strategies--whether that means changing doctors, clinics, treatment modalities, or going down a different path of family building altogether.

7. Be as proactive as possible.

Infertility is a major life crisis, and the task of having children is one of the most important things you will ever do. Thus, you must do whatever you believe will give you the best chance of success--even if it's hard, inconvenient, or expensive.

8. Recognize that some people are going to say stupid or hurtful things--no matter what.

I wish this statement wasn't true, but the fact remains that many people harbor misconceptions about infertility, or are insensitive to other people's feelings. It is a small comfort, but the fact is that people will say stupid and hurtful things about any number of subjects, not just infertility alone
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9. Try to identify who you can get support from, and focus on those relationships.

Sometimes it is surprising to discover who among your friends and family you can count on, and who you can't. Don't feel guilty about not sharing information or being as close as you were to people who, for whatever reasons, cannot be helpful during this phase of your life. You are in a crisis, and you need to focus your energy on those relationships which can provide you with support and understanding.

10. Remember to take the long view.

An important factor to consider when making decisions about infertility treatment is that you are trying to keep yourself from having major regrets later in life. Try to think about how you might feel about your decision ten, twenty, and thirty years into the future, after the window for making these decisions has long past. This perspective may prompt you to do things that are harder in the short-term in order to prevent long-term regrets. Although this is difficult, you can be confident that your future self will appreciate your hard work and sacrifice!

On loss and miscarriage after infertility

2011-09-11T13:56:00.000-07:00

Today, of course, is the tenth anniversary of the terrible events which occurred on September 11, 2001. For all of us, it is impossible to avoid thinking about where we were when we heard about the attacks. But for me, I also can't help remember what I was that day--which was pregnant, for the first time.

I was driving through Chicago gridlock to get my second hcg level drawn when I heard the news that planes were crashing into the World Trade Center. It was following my first IVF, which was a disaster all around, and worthy of a blog post in its own right. I was shocked and horrified all day long as the events unfolded. In addition, I was quite anxious and worried, waiting to hear "the number" from the IVF clinic. When it more than doubled, I was ecstatic, and yet I felt terribly guilty, feeling happy when so much tragedy had occurred.

But my happiness and excitement was short-lived. A few weeks later, my first ultrasound revealed a sac but no heartbeat. After a torturous week of waiting, another ultrasound confirmed my suspicions--I was having a miscarriage. I remember before the ultrasound appointment, I looked online at all the different stages of fetal development, and I had a feeling that my pregnancy would never progress in that way. I remember the way my husband, unable to reach my hand, grabbed my foot when the ultrasound technician told us there was not going to be a baby. I remember crying so hard in my RE's office that he escorted me out the back door of his office, I think less for my own comfort than his fear that I would scare the other patients in the waiting room.

The next afternoon I was scheduled for a D & C. I took a walk in the morning, thinking this was the last thing my "baby" and I would do together. At the hospital, things went worse. As I was waiting to go into surgery, crying the whole time, I heard the patient in the next cubicle, crying herself, only for a different reason--she had just found out she was pregnant, and therefore unable to have her surgery.

After the D & C, my hcg levels would not drop. Every week, I was back at the RE's office for more blood draws. During one of them, one of the nurses (and she was not, unfortunately, one of those great nurses we all know and love) questioned me as to whether or not she should put "pregnant" as my diagnosis--technically I was pregnant, but we all knew the situation. As do so many women who suffer a miscarriage, I desperately wanted to cycle again and get pregnant as soon as possible--but my body was not cooperating. Another ultrasound revealed that fetal matter had been left in my uterus during my D & C, so I had to have another one two months later. All in all, it was not a pleasant experience.

When the chromosomal test results came in from the D & C, the nurse was reluctant to tell me the sex of the fetus, but relented after I pressed her repeatedly--it was a boy, and the chromosomal tests came back normal, leaving the cause of the miscarriage, like so many, a mystery.

Although it has been ten years since these events occurred, I can still feel the sting of them. I am often asked by clients when the pain resulting from miscarriage and loss goes away. My best guess is that it doesn't really ever leave us, although the intensity of the feelings does lessen over time.

I have often thought about writing a blog entry about coping with loss and miscarriage after infertility, but the same thing has always stopped me: I don't have any words of wisdom about this subject. To me, every miscarriage or loss just seems really, really sad. There doesn't seem to be any way to avoid that. Although it is a relatively common experience among women, infertile or no, it still seems a very personal and cutting loss. The best I can offer is to listen to and sit with all the sad feelings that come up, and to pass the Kleenex when needed. A friend of mine, after struggling with infertility, lost her baby to a chromosomal disorder at 32 weeks, and with her, it seemed like she was grieving in some sort of emotional ditch. All I could do is crawl down into the ditch with her, listen, hold her hand, and try to bear witness to her incredible sadness.

The other odd thing about recovering from a miscarriage or loss is that life goes on, and so do we. As I watched my adopted daughter today, participating in a balloon release to commemorate 9/11, I reflected that if I hadn't miscarried my first pregnancy, it was unlikely that she would be here, in this town, on this football field, releasing balloons. I could not have loved her more than at that moment, and yet I still felt sad about the little one that never was to be. So many of my clients have reported a similar mix of happiness and grief, all jumbled together. I don't think there is any way of avoiding those feelings either.

To me, it is even more surprising that on this ten year anniversary of my first confirmed pregnancy, I find myself pregnant again, with a boy, who will hopefully be born healthy and happy in a few weeks. Like all mothers and mothers-to-be, I just hope that my children and I can make it through this day together, and for all
of the days that follow.

Our emotional relationship with embryos created in IVF: some thoughts

2011-08-25T12:41:00.000-07:00

I have been having a problem lately keeping the pet fish in our tank alive. Despite my best efforts at following all of the rules (feeding properly, changing the water often, etc), watching the fish closely, and medicating them if necessary, I have somehow become the fish equivalent of the Grim Reaper. All of this has been upsetting, but also has felt eerily familiar. When I noticed the latest victim floating at the top of the tank at 4 am today, it occurred to me that this is because this is very similar to how I have felt about the many embryos my husband and I created through our IVFs--despite all my best efforts, I couldn't seem to keep most of those alive either.

In some ways, the argument about when life begins seems like a nonstarter to me. I know all too well that an embryo is not necessarily a person. True, it contains the potential to become a person--perhaps, if all the conditions are right. But I also know that an embryo can break your heart. When people bemoan the thousands of embryos that are frozen in storage at IVF clinics around the world, it shows me that they haven't spent enough time hanging around with embryos. I know that many of those embryos would never have a chance of becoming a baby in the first place.

It is a interesting side effect of our modern age that we can now develop an emotional relationship (albeit a probably one-sided one) with embryos. During an IVF cycle, it is very easy to develop fantasies about the embryos we create. Looking at their pictures, we can imagine them growing into our beloved children. We pin all of our hopes on them. It seems to be almost a universal psychological aspect of IVF, especially in the first couple of cycles. A friend of mine, during her first IVF, created 24 embryos. She celebrated, sure she would get pregnant with that kind of haul. "It's enough for a baseball team!", she exclaimed, as we popped the champagne. She didn't get pregnant, though, and none of those embryos survived to Day 5. She didn't get pregnant in any of her ensuing IVFs, either. Not to worry, she and her husband adopted two incredibly smart, lovely girls, and are completely happy with their family, as they should be.

As for me, my first IVF was not so fruitful. I had 4 embryos that had any serious chance of success. I remember planting four plants in my garden to commemorate them. The plants later died. One of the embryos got me pregnant, only to miscarry at 7 weeks. To honor him (chromosomal testing revealed it was a boy), I planted a shrub in my garden, only it didn't take root. The next spring, I kept waiting for it to start to grow again, to no avail. I think I finally gave up in July. I planted St. John's Wort in the same spot instead--for its antidepressant properties if nothing else.
It did just fine.

Such experiences, along with the experiences I witness among my clients, make me wonder if getting emotionally attached to embryos is at all wise. However, the same experiences also make me wonder if getting attached to embryos is somehow unavoidable. Even the most veteran, jaded IVF patient seems to harbor secret, unspoken fantasies about his or her embryos, although they are long past the point of celebrating them or commemorating them in a garden. What makes this so hard is that although not all embryos are going to turn into babies, some indeed do--and it's hard to definitively tell which ones are capable of doing that at the outset. In contrast to my first IVF cycle, my last cycle was with our one last, remaining, frozen embryo, created four years ago. We cycled to complete our infertility story, but without expectation that it would result in a baby. Now, at 33 weeks pregnant, it appears this embryo had other plans, and we are hoping for a good outcome in October. But to be honest, I never would have guessed it was possible.

If you are undergoing IVF, I would caution you to try to remember that an embryo is a possibility, not a promise, of a child. However, if you find yourself having lots of feelings and fantasies about your embryos, I think that's probably par for the course. The important thing is to acknowledge how you feel and give yourself permission to process these feelings, no matter what happens in your cycle.

A bad news week for infertile and adoptive parents; public perceptions of the infertile

2011-08-15T09:57:00.000-07:00

Stolen children in Guatemala and China placed for adoption, and babies secretly created abroad via donor egg, donor sperm, and surrogacy for adoption in the US--it wasn't exactly been a "feel good" week in the infertility and adoption world. A judge in Guatemala recently ruled that an adopted child living in the United States be returned to her birth parents in Guatemala years after she was kidnapped and placed in the Guatemalan foster care system. According to the birth mother, she searched for her daughter for years but was not allowed by the Guatemalan government to investigate orphanages or foster homes in her attempts to find her daughter (more here). Whether or not the order is valid in the United States or will be followed is unclear at this time. In another news story, abuses of the family planning officials in a poverty-stricken province of China were described. Allegedly, government officials took children away from poor families unable to pay exorbitant fines and bribes, and placed them for international adoption. Presumably, they received a share in the donations Chinese orphanages receive for completing the international adoption (more here). In a third news story, a prominent adoption and third party reproduction attorney pled guilty to charges of fraudulently presenting several babies carried by a surrogate as available for adoption because their original intended parents backed out of the situation. These "original intended parents never existed". Rather, the babies were created at the request of the attorney in the Ukraine using donor eggs and sperm. The prospective adoptive families then paid $100,000 to $150,000 to assume the surrogacy costs and adopt the babies (more here).

All of these news stories are in their own ways shocking, horrible, and tragic. I cannot imagine the pain of parents having their children taken from them, and then finding that the government is either complicit or unhelpful in finding them again. Likewise, for the adoptive parents of the Guatemalan girl, I can only imagine their pain at being faced with the possibility of giving up their beloved child. Further, the adoptive parents of the babies of the surrogacy ring must be coping with many feelings as well, among them betrayal at being misled about their child's genetic and legal origins.

In addition, stories like this make me worry because it seems to reinforce a stereotype of those experiencing infertility--that we are out of control, so crazy that we will do anything to get a baby, even if it means stealing, lying or paying exorbitant sums of money. And that somehow, because of that, all of the above cases are actually all our fault. If you read the internet comments on the above news stories, you will see that my fear is justified.

Of course, this perception belies all facts. In none of the three stories described above did an adoptive parent do anything illegal or immoral. In fact, they were defrauded and abused just like the birth parents, presented with a child legally cleared for adoption, when in fact they were the victims of kidnapping or created under false pretenses. The guilt, desperation, and greed all lay on the other side of the equation--corrupt or unresponsive government officials, and the legal experts who are supposed to help them make sure that everything is above-board in the first place.

Further, the above stories are exceptions. The vast majority of adoptions are done in a legal manner, and end up happily for the children and parents involved. But those wonderful stories, which happen every day, don't make the newspapers or the rounds on the internet.

I've worked with a quite a number of infertile individuals, and I myself struggled with infertility for a long time. Not once have I ever, ever heard someone seriously contemplating stealing a child or doing anything illegal in order to have a family. Someone might make an idle comment, in the same way we might wish to win the lottery, or be in Hawaii instead of Chicago during a cold February day. But I've never heard any serious intent behind it, even though the desire to have children was powerfully intense.

As for myself, at only one point did I ever have the urge to steal a baby. This occurred before I had my own children, when someone left their baby, unattended, in a corner of a restaurant in which I was dining for over an hour (the baby was awake, by the way). I had the thought that whoever left that baby by itself there probably didn't deserve to have that baby, and it crossed my mind to pick up the infant carrier and walk out of the restaurant. But of course I didn't do that. Instead I pointed out the situation to the restaurant staff, and I left the restaurant without the baby.

At its base, infertility is a medical condition. As a society, we don't perceive people with cancer, heart disease, or broken bones as desperate and depraved in their search for a cure. So it seems unfair that infertility is still frequently associated with such negative perceptions.

It is truly a shame that the bad actions of a few individuals cause harm to the lives of so many. Although international adoption is controversial, it also has provided love and happiness to many children who otherwise, in their birth countries, would have had limited chances of finding their own families. Yet news stories like this tend to make it even more difficult for these adoptions to occur.

Likewise, surrogacy and donor gametes have helped countless individuals and couples create their beloved families. When the normal standards that govern these situations are bent, this is all the general public tends to see.

The public perception that somehow these unusual situations are caused by the intense, out of control desires of infertile individuals creates numerous problems for those struggling with infertility. People often can feel more ashamed or embarrassed by their medical condition, and they are less likely to discuss the situation with others. Not only is this difficult for them psychologically, it also makes it harder to advocate as a group for important things like medical insurance coverage for infertility.

It is my hope that as a community, we can help to correct these public misconceptions about infertility. Frequently, public perception changes with one person, and one story at a time. It isn't until people meet someone and get to better understand their situation that their prejudices are called into question. Although discussing infertility is a sensitive subject, it may be that if others can better understand our situation by hearing about it from us, they will think twice next time before they say something unhelpful or untrue.

Flexibility and infertility

2011-08-04T14:05:00.000-07:00

Lately, I've been thinking a lot about my infertility and family building career, which began in earnest twelve years ago. Perhaps, this is because, as time marches on, it is coming to a seemingly definitive end. It's been quite the adventure, to say the least, but the question that I keep coming back to is this: How did I, a woman with very serious infertility problems, manage to end up with children in the end?

As I review all the twists and turns my husband and I encountered, I have stumbled upon a few factors that I believe, ultimately, contributed to our success. Several of these factors were not in our control, but to me the most important one was flexibility, the willingness to try a different direction, even if it was not our first inclination. I can't say this was a virtue on our part, but rather a necessity--mainly because what we originally wanted, which was to have children "naturally", genetically related to both of us, and on our own time table (not to mention without significant expense), was simply not possible.

I was particularly reminded of the importance of flexibility as I read Holly Finn's excerpt of her book about her own infertility struggles in the Wall Street Journal a couple of weeks ago (which can be found here). I was moved by the following portion:

"After a recent procedure failed—we got just two eggs, and neither was fertilized—I revisited decisions and doctors.

I went back to Doc S. and asked straight out: Would a sane person bother trying again? He said, "I don't think there's anything insane about what you're doing." But he gives me a less than 5% chance of a cycle working, down from 10% to 15% when I started, and he brings up the possibility of donor eggs. That's code for "time's up."

The success rate with donor eggs is 80% on the first transfer. Many people turn to this option (one out of 10 IVF cycles in the U.S., at last count), though nearly none admit it. I can imagine using this option if I were with a man to whom I would love to give a child, but right now, I'd be match-making a couple of strangers in my womb.

I know that it's not just genes that you pass down to a child; it's also your spirit and what you believe. Still, I resist having someone else's baby.

It's because of my thumbs. The left one is long, skinny and straight—very feminine. The right is squat, thicker and curved—definitely masculine. The first is my mother's; the second, my father's. They're exact replicas. My sister has them too.

There's something about being able to see where at least some of your parts are from."

I could really identify with Ms. Finn's struggle. Part of being flexible in regards to infertility treatment requires us to experience loss. Without being able to mourn what you won't ever have, it's difficult to move on to what you could have. Although I sincerely hope Ms. Finn's treatment with her own eggs is successful, it may be that she is not medically capable of producing a child with her own eggs. That is, of course sad and unfair--but is it worth, as they say, throwing out the baby with the bathwater? This is a personal choice, of course, that we can only make for ourselves. In the end, when faced with analogous circumstances, I have chosen to hold the goal of being a parent as primary, and the genetic connection as secondary. That may not be the best choice for everyone, but it seemed to work for us. For instance, adopting our daughter from India was an amazing, albeit challenging experience, one that I would never trade for anything. However, if you'd told me a few years prior to the adoption that I was going to do that, I never, ever would have believed you. Things change.

Dawn Davenport, at Creating a Family.org, wrote a really wonderful blog post this week that also addresses this point (found here), on whether or not a child of adoption (or created in any infertility treatment for that matter) might feel that they arrived in the family as a result of "second best choice". Ms. Davenport uses the analogy of ending up in Lisbon rather than Paris as a result of circumstances, only to learn that she actually loves Lisbon far more than she could have predicted. I've also read a similar travel analogy used in regard to loving a child with special needs. Either way, the sentiment is beautiful and rings true to my own experience. Although we may really want things, in truth, we may not always be able to get them. This is not just true of infertility--it occurs in all aspects of life. Sometimes, when we refuse to give up on a specific desire, it prevents us from being open to all the other possibilities we may have.

Of course, in the case of my family, we weren't just flexible--we also got lucky. We managed to adopt in India before the process became much more difficult and restrictive. For once, we fell on the right side of the treatment success statistics. We also had jobs that provided us with time off and health insurance. We also were fortunate to have a supportive network of family and friends. For all these factors, I am incredibly grateful. But in spite of them all, without being flexible about how we achieved our goals, we just couldn't have built our family. For us, it seemed to be the most important underlying principle of our journey.

By the way, while you are reading the blog over at Creatingafamily.org, be sure to also read Ms. Davenport's post about a Dear Abby column about the appropriateness of an adoption fundraiser. It's one of the best infertility blog posts I've read lately, and really combats a lot of the prejudices and stereotypes that those of us with infertility experience!

Infertility, perfectionism, and the loss of the "dream baby"

2011-07-20T10:16:00.000-07:00

The other day, a client and I were discussing the struggle of giving up the "dream baby"--that is, the idealized vision we all seem to carry around of how perfect and amazing our offspring would be. They might have their mother's eyes, or their father's smile. They are of course adorable, brilliant, and lovable beyond belief. We are sure that if we could just have one, our other problems would seem to diminish in significance, and we would be, finally, happy.

With infertility, not only must we often experience a delay in achieving a pregnancy, but we may also be forced to give up on this vision altogether, even before the baby has been conceived. Whether it is feelings about having to use medicine or ART to conceive, the involvement of third parties, such as gestational carriers, or the loss of a genetic connection to a child by building a family with donor gametes or adoption--it all starts to be a deviation from the "dream".

There are often a lot of feelings of loss associated with giving up the idealized version of your "dream baby", and I think this is one of the factors that makes infertility so difficult to experience. Except here's the thing--no matter how your family was formed, you were never, ever going to get that "dream baby" anyway. Nobody does. Perhaps those blessed with fertility and easy pregnancies can forestall this loss until after the baby is born. But even they will at some point have to acknowledge that their child isn't perfect, can be difficult, and like all of us, has flaws and areas of challenge. One of my favorite psychoanalysts, D.W. Winnicott, wrote that in fact, parents naturally have periods of being very frustrated with and hating their child, because of the demands the child places on them. He thought this was in fact an important part of the developmental process because it allows the baby and the parents to psychologically separate, which is very important for the child's emotional growth.

It is interesting to me why we seem to hold on to our visions of the perfect "dream baby", because we don't have the same expectations of adults. I don't know any perfect adults, and I bet you don't either. So why we would expect a baby, who is just trying to figure out this crazy world, to fulfill our visions of perfection, is curious. Maybe if we didn't have this vision, we wouldn't have the motivation to keep trying to create our families.

In any case, I think that realizing that the "dream baby" is just that--a dream--makes it easier for those of us who have experienced infertility to make decisions about treatment and family building decisions going forward. If your dream baby doesn't exist anyway, maybe it might matter less to you if your child was conceived in an IVF lab, or if you aren't genetically related to him or her. Giving up on the dream baby opens us up to love and accept whomever we are fortunate enough to parent, with all of their own uniqueness, talents, and difficulties.

If you are struggling with this issue, I recommend you make a list of all of the characteristics of your "dream baby". By seeing them in writing, you may be able to better understand your own expectations. It also may help you realize what you hope to gain by becoming a parent, and that there are many paths to that goal.

Although giving up on our impossible fantasies can be painful, it does allow us to engage with our realities, which, especially when it comes to children, can still be quite amazing, no matter how they come to our family.

Infertility and health insurance: the infertility therapist gets cranky

2011-07-01T12:51:00.000-07:00

To be perfectly honest, nothing can get me quite as irritated quite as quickly as the subject of health insurance. This in many ways is ironic and possibly unfair. After all, health insurance payments constitute a large portion of my income. Also, I am fortunate to have access to quality medical insurance for myself and my children. To top it off, I spent my entire infertility career living in Illinois, one of the few states to have some form of state-mandated infertility coverage. So really, I know I should have little about which to complain.

And yet, I found myself flooded with those old familiar feelings yesterday, as the less-educated insurance company managed care employee, who had never met my client, demanded during a phone call to know why I had seen Mr. X for more then twenty sessions, and when I was planning on discharging him already. The answer, "Whenever I damn well feel like it!", though running through my head, would not have helped Mr. X get reimbursement for the treatment he needed and wanted. So instead, I played the game, repeating the phrases that insurance companies need to hear, in order to secure continued coverage. I was made even crankier by the realization that since the passage of the Mental Health Parity Act, which went into effect last summer, the insurance company really could not legally limit Mr. X's sessions. But by requiring superfluous clinical reviews, they could put another hurdle between him and his insurance benefits. If I had not followed through with their request, they could have denied his claims--even though this would not have been his fault.

Further, these types if policies have a psychological impact on clients' views of themselves. Although they may feel quite distressed or that therapy is very helpful to them, if an insurance company questions its validity, authorizes only a limited number of sessions, or denies coverage, they often feel their own experiences are invalidated. After all, the "experts" have deemed that their problems are not serious, or that treatment isn't medically necessary. This often causes a serious disruption in the treatment. Now, in addition to working on the original issues that caused them to seek therapy, we must also deal with the feelings of invalidation stirred up by the insurance company. All this while insurance companies are recording record profits--for instance, the local Blue Cross/Blue Shield organization in Illinois just posted a $1.1 billion profit for 2010 (more information here).

When it comes to medical coverage for infertility, the problems are even more severe, for the infertile have much less protection under the law than those with mental health issues. In many states, there is little or no coverage for infertility. There seem to be two main arguments for doing so. The first is that infertility treatment is very expensive and will prohibitively increase insurance premiums and health care costs. However, research suggests otherwise. A 2006 survey demonstrated that when employers did offer infertility coverage, 91 percent of them experience no increase in costs (full study available here).

The second, and to me the more troubling reason, that infertility treatment often isn't covered is that it is not considered a "medical condition". On the face of it, this seems absurd--infertility is generally caused by medical problems and issues, which prevent a person's body from functioning as it should. However, the perception is that infertility is not life-threatening--if you can't have children, it won't kill you. Of course, medical insurance generally covers treatment for a whole host of other ailments that aren't life-threatening, but nonetheless reduce the quality of life from a medical perspective (male impotence being perhaps the most famous example). Mental illness has been perceived similarly, and thus has been covered at much lower and restrictive rates. It took years of active advocacy by the mental health community to begin to change this perception and to garner support for the idea that it should be treated as any other type of medical illness. I suspect that the same type of advocacy will be required of the infertility community.

While lack of insurance coverage for infertility is problematic from a financial and practical perspective, it also troubling from a psychological one. As I have discussed in other blog posts, people with infertility have a tendency to blame themselves for their infertility and to feel a great deal of shame around it. When the insurance company confirms this by refusing coverage or payment, it then provides them with "confirmation" that their beliefs about themselves are true. In my opinion, half of the battle in dealing with infertility is trying to take the self-blame out of the equation, and instead conceptualize it as more of a medical issue. Further, feelings of shame and self-blame often make it more difficult for those struggling with infertility to successfully weave their way through the bureaucratic maze of paperwork and phone calls required to get the insurance coverage to which they are entitled.

I understand that health insurance is a business, and that insurance companies need to make money. It's clear that they are usually very successful in this respect. But it seems to me that to use societal prejudices to deny coverage to those who need to treat a medical condition, such as infertility, is going a little too far in the name of profits. Further, making it purposefully difficult for their policy holders to access their benefits by putting up red tape and road blocks crosses an ethical line as well. Hence all the crankiness.

I've been dealing with health insurance companies in my personal and professional life for the last eleven years, and I have learned a few strategies of coping with the situation. First and foremost, you have to look at any communication between you and your insurance company as a possibly adversarial one. This doesn't mean you should start off by shouting at or fighting with insurance company employees. However, you should recognize that the insurance company's interests and your own personal interests often conflict. Therefore, I suggest you do the following:

1. Always write down the name of the person with whom you are dealing, as well as the date and time of the call. This way, if someone tells you something later that contradicts the information you received, you can refer them back to this prior conversation. Most phone calls are recorded, and you can even ask them to pull the recording for the call.

2. Never assume that the first answer you are given is the correct one. Particularly in complicated situations, such as infertility, the call center employees are often struggling to find the information you request, and they don't always have expertise in the area. If you get an answer you don't like or doesn't make sense, make a record of it, and then call back and ask the same question of someone else.

3. Insist on speaking to a supervisor should any problem arise. Often, you will meet resistance at this request--the employee will tell you that the supervisor can't tell you anything different or do anything else to resolve your problem. I always tell them that I am willing to risk that possibility, and to get the supervisor anyway. Once you are successful in reaching a supervisor, get that person's name and direct line if possible, and call them every time you have a question or issue until the problem is resolved.

4. Educate yourself and know your policy. If you read your plan document, you can refer to it during conversations with the insurance company employees, and many times show them they are wrong. Also, it pays to know your legal rights in your state, in terms of coverage, appeals rules, and how to make complaints against your insurance company if necessary.

5. Don't give up. If you think you are right, then you need to keep fighting. The insurance company may not be particularly welcoming of this, but if you appeal their decision, many times it is overturned. It's hard to keep going when it so irritating and discouraging--but use your anger and crankiness to provide you with the energy you need to get the coverage to which you are entitled.

For the infertility "veterans"--psychological implications of long-term infertility treatment

2011-06-23T09:11:00.000-07:00

Infertility treatment, whatever it's duration, is stressful and often difficult. For the majority of people, however, it's of relatively short duration--within a year or two, a pregnancy is achieved or a diagnosis is clarified, leading to a different path.

On the other hand, there is significant subset of infertility patients for whom treatment spans many years, sometimes even more than a decade, before any sort of resolution occurs. Perhaps this occurs because there is no clear diagnostic picture, or because they have tried multiple, time-consuming ways to build their family without success. Sometimes, life circumstances require them to take longer breaks from treatment. Whatever the case, being in infertility treatment for a prolonged period of time can definitely take its toll on a person.

Bitterness is often the main worry of the veteran infertility patient. After so many disappointments, it can feel hard to be hopeful for the future. Watching friends, family, and coworkers create their own families with less effort and stress makes them feel chronically isolated. Despite their best efforts, these feelings may seep into other aspects of their lives and relationships.

Further, one of the hardest parts of infertility "veteran" status is that after years of trying and failing, an individual can start to feel alienated even from the infertility community itself. I have had more than one client in this situation discuss how they feel they are left behind by all of their infertility friends who go on to have treatment success. Unbelievably, he or she begins to feel envious of other infertility patients. It can start to seem that all the other patients in the waiting room have a better chance of success. When listening to the emotional experiences of "newbies", or those just entering infertility experience, the "veteran" often feels irritated and impatient. The mix of hopefulness along with the anxiety that is so common in the beginning stages of infertility treatment is often painful to hear--the veteran remembers all too well how he or she used to feel hopeful as well, only to end up with multiple painful disappointments. Usually, the veteran infertility patient feels ashamed or guilty about feeling envious, impatient, and irritated with other people, because he or she really wants to be helpful and share his or her hard-won expertise. It is often difficult to recognize that in addition to our altruistic impulses, we also experience negative emotions such as envy and anger. Sometimes, this dilemma can have a further negative impact on the veteran's self-esteem, on top of the damage done by years of protracted infertility.

On the positive side, veteran infertility patients have almost always learned from their prior experiences, and are extremely wise and educated participants in their treatment. They have a clearer idea of what they expect from their doctors and clinics, and they usually make excellent treatment decisions. In addition, they know from experience they are resilient, and that they are survivors. They can be empathic to others who are suffering from a variety of life crises, because they have themselves been in crisis for years. They understand how complex emotions and relationships can be. I believe that when veteran infertility patients do become parents, they are extremely well prepared for the stresses involved in raising a child.

If you find yourself in the "veteran" camp, know that you aren't there all by yourself. For instance, I'm right there with you--with an eleven year infertility treatment history (or as I jokingly call it, an "infertility lifestyle"). It's important for infertility veterans to recognize all the knowledge and strength they have gained from their experiences. Learning things the hard way is probably the most effective form of education, and being an expert has its advantages.

Also, I think the most important thing infertility veterans need to do is to keep trying to achieve their goals, in whatever way they feel will be most successful for them. The temptation to give up is strong, especially when faced with the possibility of future disappointments. However, the risk of profound future regret is real. Thus, endurance, and lots of it, is vital to this process. In order to maintain their ability to keep going, infertility veterans must take special care of themselves to ensure that they do not become emotionally and physically depleted. Being in a chronic state of crisis is exhausting, and it requires good emotional support to not become overwhelmed. Further, pacing is key here--a person can't be full-steam ahead in infertility treatment all the time! Making time for pleasurable personal interests--hobbies, friends, travel, etc., can be really helpful.

Finally, I sincerely hope that if you are an infertility veteran, your infertility career will be over soon, and you will soon have the family you for which you have worked so hard! I would love to hear about your own experiences and perspectives! As always, please let me know if you have any questions, comments, or suggestions for further topics.

When infertility happens to good people: bad luck or somehow "meant to be?"

2011-06-13T08:52:00.000-07:00

How many times have we heard the cliche that "everything happens for a reason"? On the face of it, it is a very tempting thing to believe, especially if it involves a good outcome. Of course, we were meant to be at the party where we met our partner, or to happen to run into that old friend who told us about that latest job opportunity. It seems many people believe that much of what happens to us isn't due to chance, but is somehow preordained. This usually provides a measure of comfort; life is not a random series of events, and it usually involves some benevolent spiritual force that is looking out for us, and has our best interests at heart.

It all works well...until something bad happens. Then the once-comforting belief now raises a bunch of unsettling questions. If the bad event was meant to happen for a reason, what was it? For instance, why do natural disasters happen, or do little children suffer painful and horrible illnesses? The answers are often not immediately apparent.

When experiencing infertility, the idea that it may have happened for some higher purpose can be troubling. I cannot count the number of times I have heard clients struggle with this issue, and they always seem to come up with the same answer: for some mysterious reasons, they are not meant to be parents. This worry usually only increases the painfulness of their situations. They cannot help but reflect that the situation seems so unfair. There are so many examples of people who are clearly problematic parents but who seem to have limitless fertility. They search their life for hidden sins or exaggerate the importance of minor flaws, all in the service of discovering the "reason" their infertility has happened to them. Eventually, they come up with quite complicated, convoluted theories about their alleged unfitness to parent, almost all of which appear, to me at least, to be patently untrue.

In addition, those struggling with infertility often must also contend with the comments others make about how "when it's meant to happen it will", or how they should just relax and trust God or fate or whoever or whatever is supposedly in charge of these things. These comments often add to their worries about themselves as potentially unfit parents. Further, they now are concerned that the feelings of sadness, impatience, and anger they feel aren't normal--shouldn't they just "relax and let it happen"?

Although I would never claim to have the answers as to whether or not things happen for a reason, I do know this: I have myself been infertile for a long time, and I have talked to many people who have also struggled with infertility, as well as people who have suffered many other types of terrible losses. I myself have never been able to piece together a convincing reason that all of these bad things happened, either in the individual cases, or collectively. Rather, I think that it is more likely that there is a lot of random chance at play. Out of 100 couples, 8 of them will experience infertility for separate and different reasons. I happened to be in the part of the population that is infertile, for various medical reasons, some currently diagnosable and some not. If you are dealing with infertility right now, I think the same is probably true in your case. I doubt it has much to do with your personality, your goodness as a human being, or your fitness to be a parent.

The downside to not believing that everything happens for a reason is that it is, from an an emotional perspective, scarier to live in a world where events are affected by random chance. After all, that means that all bets are off; anything could and might happen, even if it is not particularly likely. On the other hand, it does save us from creating explanations of difficult or tragic events that cause us to feel terrible about ourselves, and that seem unlikely to be true. Plus, it makes us appreciate our good fortune when it occurs--it isn't just "meant to be". It is the result of some good luck and our hard work combined. This can help build self-esteem. Further, we can be more empathetic with others who have experienced misfortune as well, for we understand what it feels like to end up on the wrong side of random chance.

The great divide? "Us vs. them" feelings and infertility

2011-05-30T19:08:00.000-07:00

Sometimes when things get ugly, your real feelings reveal themselves.

Such was the case during an argument I had with my husband when I was pregnant. I had my 20 week ultrasound coming up, and I really wanted him to attend the appointment--I was nervous I would find out something was wrong with the baby, and I also wanted him to be part of the experience. He wanted to go too--but his boss at the time had different plans. Although he had blocked the appointment time on his calendar out for a month, his boss was insistent that he go out of town that morning, and only that morning, to soothe the worries of a nervous client. To my husband, attending the meeting didn't seem like a good idea in any case, because he would not be available to work with the client permanently. When my husband explained both his general reservations, and that he had a personal obligation and could not attend the meeting because he had a medical appointment, his boss was not pleased. He repeatedly pressed him to reveal the reason for the appointment. When, under duress, my husband told him about the ultrasound, his boss was quiet for a moment. Then he said, "You know, I have four children, and I never went to any of their ultrasounds. I don't think that's very important. What's the big deal anyway?" He told my husband he needed to go home and think about his priorities.

You can imagine the argument that ensued later that evening. I was shocked that my husband began to question his own decision to go the appointment. "Is it really that important?" he asked. "Are you kidding me?" I responded. "Don't you remember what we've been through all these years? And what it took to get to this point? Half a pregnancy under your belt, and you are already thinking like a breeder!" The word, ugly, fell off my tongue.

Now it was his turn to look shocked. He paused and said angrily, "Don't you ever, ever, call me that again!"

That's when I realized it--"breeder" was now the most vile thing we could say to each other. It was the ultimate throw-down in our relationship. It was clear even though we were not conscious of it, because of my infertility, we both felt like we were in a minority group, separated from the rest of the fertile world.

To me, that's a real problem, because most of the people whom I love have no fertility problems whatsoever. I don't want to feel separate from them. On the other hand, I can't deny the fact that infertility is often painful and unfair, or that many times, people without fertility issues say insensitive and thoughtless things. Or worse, that some people, like my husband's former boss, take their fertility and good fortune for granted.

In my conversations with others with infertility, I know that my husband and I aren't alone in this struggle. Too often, the infertile folks feel left behind, out of sync, and separated from the rest of the world. While they are undergoing treatment and enduring disappointments, the rest of their peers are, seemingly effortlessly, having babies. The situation, by its nature, is divisive, with its "have and have not" undertones.

I have come to realize that one of the great tasks of life, at least from a psychological perspective, is to be able to honor your own unique experiences while simultaneously recognizing the different experiences of others. It takes a lot of emotional energy and maturity, and it is hard to do when we are in pain. However, I feel that even in the throes of infertility treatment, it is vital to try to do so. Although others may never be able to understand us and our experiences, we must still try to understand them. Without this, we risk being permanently cut off from the 92 out of 100 couples who do not struggle with infertility, even if it is in unconscious or subtle ways. This can keep us from fully dealing with our feelings of anger, grief, and loss, and can prevent us from moving forward after our infertility issues have been resolved.

Thus, although it is doubtful that my husband's boss could ever understand my feelings about my ultrasound, I realized I must try to understand his emotions. It seemed that he hadn't considered that there was anything to be nervous about during his wife's pregnancies, and that he was lucky enough that everything went well. That he didn't seem to fully value his own good fortune, and that he would clearly pick a client above his family, struck me as sad. I wondered whether or not, in the long-term, he would feel good about these choices. Seeing him as a person struggling with his own issues, and not just a "breeder", helped me to bridge the divide between myself and the fertile world.

I would love to hear about other experiences with this issue. Do you feel separate somehow from the fertile people in your life? If so, how did you deal with it?

Thanks so much for reading, and as always, if you have any questions, or have any ideas for future blog posts, please let me know!

Do mind/body programs significantly raise IVF success rates? A new study.

2011-05-26T08:05:00.000-07:00

I stumbled across this article the other day, which can be found here, describing a new research study by Alice Domar, Ph.D., et al. It will be published in the next issue of Fertility and Sterility. They authors found participation in a mind/body treatment program during IVF cycles significantly improved success rates (52% in the treatment group vs. 20% in the control group). Mind/body treatment is usually offered once weekly for several weeks in a group setting. It combines cognitive behavior therapy, mindfulness and relaxation therapy techniques, and yoga.

At first, I was excited by this news, as I've been a fan of Dr. Domar's work for some time. I think that she has created a very helpful, cost-effective clinical program to help individuals deal with the stress surrounding infertility treatment. However, I was also curious to see the details of the study, because prior research has not consistently demonstrated that participation in a mind/body treatment program is correlated with an increase in treatment success. Further, it often seems that when study results are reported in the mainstream media, they results are often misunderstood or presented as conclusive facts.

The study, which can be found here, was done with 143 women beginning their first IVF cycle at Boston IVF. The women were randomly split into two groups. In the treatment group, the women were offered 10 weekly mind/body sessions. In the control group, the women received spa gift certificates every three months. The two groups of women were not significantly different except for two variables. The women in the treatment group were more likely to work full-time. Also, the embryos of the women in the control group were much more likely to be fertilized using ICSI. This was probably because the women in the control group had a much higher rate of male factor involvement in their infertility treatment (20 percent versus 8 percent in the mind/body treatment group).

The study followed the women over two IVF cycles. In the first IVF cycle, pregnancy rates were the same--43 percent of the women in the treatment and control groups had confirmed clinical pregnancies. However, in the second IVF cycle, the women in the treatment group had a significantly higher pregnancy rate--52 percent--versus the control group, who had a pregnancy rate of 20 percent.

The authors theorized that the reason there was no significant difference in the pregnancy rates during the first IVF cycle was because most of the women in the treatment group had not actually received the mind/body treatment yet. They had predicted it would take longer for the women to start cycling, and the mind/body program is not continuously offered at all times. They argued that the pregnancy rates were higher for the treatment group in the second IVF cycle because by then, almost all of the women had actually attended at least six to ten treatment sessions.

On the face of it, all of this sound pretty good, right? However, when I started really looking at the numbers, I became less convinced. To me, the first troubling issue with this study is that the treatment and control groups were not really diagnostically similar. In the control group, male factor infertility was a much more prevalent cause. Indeed, when the authors reran the statistical analyses to control for male factor infertility, the difference between the second IVF cycle success rates were no longer statistically significant.

Further, the study had difficulty recruiting, and in some cases retaining, participants. This meant that for the second IVF cycle, in which they found their significant results, there were only 21 women in the treatment group left, and 20 in the control group. With such a small sample size, it is difficult to make generalizations to the general IVF population. As the authors point out in the article, it may be that women who are willing and able to participate in a research study, especially those who can attend weekly treatment sessions, may be different than women, who for whatever reasons, cannot. These differences, not the mind/body treatment itself, may be the cause of their higher pregnancy rates.

Thus, I think it is premature to conclude that mind/body programs can significantly improve pregnancy rates for IVF. Further study in this area clearly needs to be done to provide us with more information.

I realize touches on a controversial issue, because there are so many strong and conflicting opinions about whether stress plays a role in causing infertility. For many, the last thing they want to hear is that their own emotions are causing their infertility woes. In contrast, others would love to believe that if they could just change their feelings or mindset, they could transcend the physical difficulties they may have. To make matters worse, the research in this area is all over the map, with some studies showing that stress or depression impairs fertility, others showing it has no effect, and some showing that moderate stress increases fertility rates.

Regardless of the research on pregnancy rates, I still believe that mind/body programs can be very useful during infertility treatment (and probably during a lot of other life difficulties, too). Anything that helps us deal with stress, reconnect with our bodies, and provides support is beneficial. But I wouldn't go into mind/body treatment expecting it to significantly increase your chances of achieving a pregnancy. The way I see it, it might help some people with certain diagnoses to conceive. However, there are also probably some people for whom decreasing stress levels won't change their physical situation, and their chances for pregnancy would remain the same.

Regrets and infertility

2011-05-11T13:38:00.000-07:00

One of the most difficult issues that individuals struggling with infertility face is that of regret. Whether it is about treatment decisions, or decisions about when or with whom to start trying to have a family, regret can be very difficult to tolerate.

I think I have always been particularly sensitive to feelings of regret because even as a young child, I was very aware of my maternal grandfather's own regrets about his life. He always regretted not pursuing higher education when he had the chance, and expressed bitterness about his choices. In my own life, I have used these memories as a constant warning. I frequently find myself thinking about how I might view my decisions in the future. Although I feel that this has helped me make some good choices, it has hardly made my life regret-free.

I have come to the conclusion that despite our best efforts, it simply isn't possible to avoid having regrets entirely. The cliche that hindsight is always 20/20 is oft-repeated because it is true. But in addition, I think that no matter how much research we might do, and no matter how much we weigh the pros and cons of things, we sometimes only learn things the hard and painful way. There is little more instructive than a profoundly painful experience; we usually learn the complicated nuances of that situation very thoroughly and quickly.

Of course, infertility treatment usually presents all sorts of complicated situations and decisions. The best course of action is often not obvious. So we must make decisions using the knowledge, abilities, and emotions we have at the time. When they turn out to be decisions we later regret, it is usually because we learned so much dealing with the aftermath of those decisions. We are now functioning with a whole new level of knowledge and expertise. With our new vantage point, we now see the better option. So in a way, without making choices that we later regret, we may be unable to develop the knowledge and judgment we will need to ultimately succeed. Feelings of regret are, in actuality, the "cost of doing business".

For me, I have struggled with regrets that I did not pursue IVF right away when I first learned I had infertility problems. My RE at the time told me that I was subfertile, not infertile (history has proven it otherwise), and thus I continued trying on my own, and then tried less aggressive treatments to no avail, for almost 2 years. Little did I know that each month, my FSH was rising and my ovarian reserve was declining at a rapid pace. However, at the time, I didn't really know to even ask about those problems. Once I figured out what was going on, however, I was able to change my attitudes about treatment, and eventually achieved success. Now, of course, in my work with my clients, this is an issue I investigate right away--because I learned about it the hard way, it is almost a reflexive response.

Thus, I think problems with regret arise only when the regretful feelings cause a person to become unable to move forward in their lives. Perhaps they now have a crisis in confidence, and feel unable to trust their decisions. Or as my grandfather did,perhaps they blame themselves for circumstances that were out of their control. In truth, my grandfather could not have pursued college when he was young because my grandmother became seriously and chronically ill, and he needed to make as much money as he could to pay her medical bills.

If you find yourself struggling with feelings of regret about decisions in your infertility treatment or family-building choices, it is important to keep in mind that regret is unavoidable. However, being stuck or paralyzed due to these feelings is something we can change. Forgiving yourself for not knowing then what you know now is an important part of this process.

Unexpected help, unlikely alliances, and other surprises along the journey of infertility

2011-05-05T18:54:00.000-07:00

For me at least, experiencing infertility has been a life changing experience. Perhaps most profoundly, due to my infertility, I found myself traveling down paths in life I would have never predicted. In so doing, I met some amazing people, and developed a greater understanding of myself and the world as a whole.

When experiencing infertility, it is very easy to get stuck in all the negative feelings surrounding it, simply because they hurt so much! It's also easy to focus on all the hurtful things others say and do in regard our infertility. In the shuffle, sometimes the positive, helpful, and supportive things that people do for us can get short shrift.

As a psychologist, who spends her work days helping people deal with their painful feelings and experiences, I am probably more vulnerable to focusing on the negative than most. However, during the last couple of weeks I have been poignantly reminded, due the sudden illness and death of a dear relative, of how profoundly I was helped during my own journey to motherhood.

As you may have read in my other blog posts, we adopted our oldest daughter from India when she was an infant. Our adoption process went unexpectedly quickly, and we took her into custody very soon after we had finished infertility treatment. In fact, while I was in India with her, I was still coming off all the hormones I had taken in preparation for my last-ditch (and failed) FET. Although I was thrilled to be adopting my daughter, I think it is safe to say that I was still in the process of understanding and working through my infertility experience.

Due to the legal process in India, we were able to take her into custody right away, but could not leave the country until our case was processed. Thus, we decided that I would stay in India with her for the 3-4 months it took for the court case to be completed. My daughter and I stayed with my husband's aunt and uncle, whom I had never met.

As you may imagine, I was completely overwhelmed by this experience. Getting a new baby, new family members, and a new culture at the same time was a lot to comprehend. My husband's aunt was insistent that we not hire a nanny, as is common in India, to help look after the baby, in order that the baby and I bond. I still feel this was the right decision, but being alone with sick infant, I got sleep-deprived, and thus quite emotional, very quickly. My husband's aunt had never had children of her own, so sometimes her expectations of the baby and me were a bit unreasonable. Her husband seemed a little disinterested in the situation, or perhaps a bit unsure of what to do with this fussy baby and crazy American who had suddenly taken up residence in his apartment. One day he had promised to take me to a department store after he came home in the evening so I could buy some things for the baby. I hadn't left the apartment in days because I was intimidated by the streets of Mumbai, and I didn't know where to go, so naturally I was really looking forward to this outing. When he came home, however, he said he was tired and that we would go some other time. I got very upset--and I am ashamed to say I threw a bit of a tantrum, complete with tears and door slamming. To my surprise, he came into my room a few minutes later, and asked why I wasn't dressed to go out. I received no reprisals for my behavior, just a smile.

As we walked through the streets of Mumbai, we came to an extremely busy road that we had to cross, with no crosswalk or stoplights in sight. I stood at the edge of the road transfixed with fear--how would I ever cross it? To my surprise, my husband's uncle calmly stepped into the middle of traffic, staring at the drivers with his arm outstretched--and the cars quickly stopped. Having lived in Mumbai for so many years, I am sure for him this was old hat, but to me, it was magic. Had I been by myself, I think I would still be standing there, eight years later, trying to figure out how to get to the other side. With his help, however, we crossed the road with ease.

Sometimes I think it's just as simple as that--in dealing with infertility, we all get stuck by the side of roads we don't know how to cross. And by having help from just one person, just for one moment, to show us how to do it, and to support us, we can learn how to keep going towards our goal, even if it scares us silly.

After that day, my husband's uncle became my biggest helper and ally. Whenever I needed to go somewhere unfamiliar, or to a doctor for my daughter, he went with me. If there was any sort of ruffled feathers between my husband's aunt and myself, he quietly smoothed them. And at 7 pm, when my daughter routinely started screaming for 2 hours straight, he would come and take her out the porch swing, sit with her on his lap, and sing her songs to give me a break. Of course, I tried to thank him all the time for everything he did for us, but he would have none of it. "You Americans are always saying thank you all of the time! In India, we do not say thank you to our family members, because we are just all doing our duty. Please no more thank you's!"

My husband's uncle died today after a short but intense bout with cancer, and I must say that although I am no longer allowed to thank him, I shall remain grateful to him for the rest of my life. If I hadn't experienced infertility, so severe that it pushed me onto a plane and into a far away new land, I never would have gotten to know him, or appreciate his kindness, much less get across that Mumbai street.

And that's the thing about infertility. While you are in the midst of it, it feels horrible, and often all-encompassing. It feels as if nothing good will ever come out of it. But in retrospect, I can see that it pushed me out of my comfort zone, and into a whole different life, with a higher level of appreciation for the people in my life. I am not one of those people who believes everything happens for a reason, because there are too many awful things that happen for which I can find no justification. I do believe, though, that we must make the best of the circumstances in which we find ourselves, and in so doing, we can learn and grow a great deal.

In your own infertility journey, I suggest that you also be on the lookout for support from sources you might not anticipate--chances are, at some point it will be there for you. Although it won't take away from the pain of infertility, it can soften the blow, and sometimes teach you new ways to approach problems.

Does infertility treatment have to take over your life?

2011-04-28T12:25:00.000-07:00

It's National Infertility Awareness Week, which is a great thing. Despite much progress, there is still work to be done to help the general public understand that infertility is a medical illness and deserves to be treated as such. Like other illnesses, it should be covered by health insurance. In addition, raising public awareness that infertility is not a result of one's feelings ("Just relax!) or one's choices ("Maybe you should have started sooner!") would be extremely helpful to those experiencing infertility now or in the future.

Still, I can't help but be struck with the irony that although the general public needs increased awareness of infertility issues, those personally struggling with it are usually all too aware of their infertility. Indeed, one of the hardest things about infertility is that it can completely take over your life--psychologically, cognitively, and practically. In this post, I'll discuss some of the psychological implications that arise when infertility is the major focus of your life, and offer some strategies about how to cope with this vexing problem.

During my first IVF cycle, I was overwhelmed by the incessant nature of treatment. Not only was I worried and anxious all the time, but the sheer physical tasks of giving myself several shots a day, and of getting to all my early morning appointments to a clinic an hour away, exhausted me. It was very difficult to fit in, much less concentrate on, that pesky job I had at the time. I don't think I spoke to my husband or friends of much else other than infertility, IVF, and how much Chicago traffic can suck (trust me--a lot). I remember joking that I had turned into an "infertilibot" and was no longer an actual person. Unfortunately, I don't think my experience was in any way unique. Almost all of the clients I have worked with have felt similarly during their cycles, especially the during first one--because everything is new, it take more mental energy to understand and process the experience.

Many times, clients have asked me how to prevent their infertility treatment from taking over their life. My stock answer is invariably disappointing, because to be honest, I think that to some extent, infertility treatment taking over your life is inevitable. Having it as your nearly sole focus is the "cost of doing business" in this situation. No matter how you look at it, the treatment it complicated, and it requires a great deal of careful attention to make sure you are giving yourself all the correct medications at the correct times. Further, it takes time and effort to follow all of your bloodwork and ultrasound results so that you can understand the treatment decisions that are made. In addition to being complicated, infertility treatment takes up a lot of time. There are frequent injections, appointments, and phone calls. So even without any emotions thrown in the mix, you have all the makings of a difficult and stressful time.

Of course, it's very rare to not have a lot of feelings about infertility treatment--so you have the added task of managing your emotions. To make it more difficult, these emotions are usually involve sensitive issues such as self-esteem, social comparison, and feelings about your body. With no extra shots or appointments, managing your emotions about these issues would be more than enough for one person--but in infertility treatment, you must manage both the practical and emotional considerations.

Although I paint a rather dire picture of the infertility "lifestyle", there are a few things you can do to make things a bit easier on yourself. By having realistic expectations, working to prevent your self-esteem from being damaged, and using distraction, you can make this situation more comfortable.

Have realistic expectations

Given the requirements of infertility treatment, in order to do it well, it must be a large focus of your energy. That's why I think it is important to be realistic about what you can expect from yourself during treatment. It's unfair to expect yourself to sail through IVF without stress, fatigue, and the occasional meltdown. Many times, I have seen clients beoome quite upset with themselves during a cycle because they can't perform to their normal level of excellence at work or at home. This only makes an already difficult situation worse. Recognizing that you can only
do so much takes the pressure off of you. I often tell clients that their infertility treatment, because of the importance of having children in their lives, has to be their central focus. All other activities are lower down on the priority level. That doesn't mean that you should stop showing up for work, or that you should let the dishes pile up for weeks, but it does mean that you may need to just do the bare minimum to get by for a short period--knowing you will catch up when it's over.

Protect your self-esteem

Infertility treatment can be very hard on self-esteem, as I've discussed at length in a few other blog posts. That's why I believe it's important, especially during an active treatment cycle, to have the following mantra: "It's a medical illness, and not a commentary on me as a person or future parent." I found myself needing to repeat this to myself over and over during my many treatment adventures. For instance, if you get a disappointing result, it can start to feel like you've "failed", even though you followed all the instructions, went to all the appointments, and did everything you could to ensure success. Keeping in mind that infertility treatment, at it's core, involves medical issues that we often can't control, can be comforting in these situations.

Distraction is your friend

Sometimes, the only way to get your mind off of infertility during treatment is to provide yourself with frequent mental "mini-vacations", whether they take the form of going to the movies, reading books, or fun activities with your partner or friends. It's important to remember that because you are preoccupied, it will be more difficult to distract yourself than normal. That's why you need really, really good distractions--things that are special treats, and things that you absolutely love. Although such distractions can be short-lived (because you have to do that next round of shots at 8 pm, for example) they can be emotionally replenishing. Additionally, they give you something to look forward to, and help pass the time until the cycle is over.

Although being in infertility treatment is difficult and can be all-consuming, if you must continue in treatment, it does get easier. As someone who has actually lost count of the number of IVF transfers I've done--is it 8 or is it 9?--I can say with confidence that the coping skills you develop during the first cycles definitely help you out in later ones. As long as you set realistic expectations for yourself and your cycle, you will survive it. Infertility treatment doesn't last forever, and before long, you will be able to focus on other things.

Are some types of infertility evolutionarily advantageous?

2011-04-21T08:29:00.000-07:00

I read a really fascinating article in the most recent issue of Fertility and Sterility, which can be found here. The article, by Azziz, Dumesic, and Goodarzi, discusses the ancient existence of polycystic ovarian syndrome. The authors investigated how a disorder, which causes subfertility or infertility, could still persist at a relatively high level in modern times--theoretically, wouldn't it have been "bred out" of the species? It appears that increasing rates of obesity in Western cultures has not caused an increase in the rates of PCOS, so it is unlikely that change in diet has increased the prevalence of PCOS in moden times. The authors offered an intriguing explanation--that for much of human history, having PCOS has actually been advantageously adaptive, meaning that women with PCOS were more likely to survive and pass on their genetic material to the next generation.

It seems likely that PCOS actually had several adaptive advantages. In hunter-gatherer societies, food was often scarce. Women with PCOS, because of their insulin resistance, use food resources more efficiently. Their capacity to store food energy is greater, and they expend fewer calories, making them better able to survive times of starvation.

Further, because PCOS frequently causes subfertility rather than total infertility, women with PCOS had fewer children spaced farther apart in time. This was advantageous in a number of ways. With no or limited birth control, women often spent much of their life pregnant or giving birth. Even in the recent past, childbirth was extremely dangerous for women and was the top cause of female death. Thus, limiting the number of childbirths increased a women's likelihood of survival. In addition, by having fewer children, women with PCOS were more able to secure their children's survival--they more easily garner sufficient resources for them. Furthermore, children were more likely to survive if they were being raised by their biological mother, so the fact that women with PCOS had longer lifespans further enhanced their children's survival rates. In sum, it seems that for most of human history, having PCOS was actually a blessing, not a curse.

I think that looking at PCOS from the evolutionary perspective in this article has some valuable psychological implications. Most importantly, I think it is useful for anyone who is currently struggling with PCOS to realize that the disorder actually has some very important adaptive advantages. This will help them have more positive and less conflicted feelings about their bodies. Too often in infertility treatment, we end up feeling as if our bodies are vexing or failing us. Realizing that our bodies are actually trying to help us, although admittedly in a frustrating way, can be a reparative experience.

Looking at PCOS from an evolutionary perspective also made me wonder if there are other infertility diagnoses that have some of the same survival advantages. For example, could premature ovarian failure similarly enhance a woman's, and her offspring, chances of survival? When dealing with infertility, it is very easy to forget that for many men and women, both throughout history and in the present-day world, fertility has actually made their lives incredibly difficult. Perhaps the grass isn't always greener on the other side of the fence after all.

Does age matter? Psychological implications for women of the age of onset of infertility

2011-04-11T18:09:00.000-07:00

Infertility is a label that encompasses a vast diversity of medical diagnoses and life circumstances. Although 1 in 8 couples will struggle with infertility at some point during their lives, their individual experiences can be quite different. One such difference is the age of onset or diagnosis of infertility, as infertility can occur at any point during a woman's reproductive years. In this post, I'll discuss some of the different emotions infertility can produce depending on the age of the woman involved. Although age also plays a role in how men experience their infertility, it seems to be less powerful factor than for women, for whom age and fertility potential are closely linked. Thus, I'll mainly be focusing on this issue from the female perspective.

Psychological implications for being diagnosed while "young"

Although everyone's experience is different, it seems that for the "under 35" set, certain emotional themes are more likely to come up when infertility occurs. The main one I see in my practice is a feeling of shock, especially at the beginning of diagnosis and treatment. In the majority of cases, women who have always enjoyed good health and normal gynecological functioning assume that they will be able to have children without help as long as they don't "wait too long" and start trying in their 20's or early 30's. It is thus often difficult to accept that there is a problem.

Once the knowledge that there is a problem sinks in, it is often accompanied by feelings of failure and low self-esteem. I have heard so many wonderful, successful women tell me that because they are having difficulty conceiving a child, they feel inferior to their peers. They worry that they have done something wrong, often on a karmic level, to cause their infertility. They tend to feel angry at and betrayed by their bodies--why aren't they working in the manner nature intended? Further, these negative self-feelings come at a time when their friends, relatives, and peers are busy building their own families, seemingly without effort. Thus, women in the "under 35" age bracket tend to feel left behind from a developmental perspective, and can often experience social isolation. To make matters worse, because they are in the typical family-building time of life, they are often subject to intrusive questions on the parts of others about when they are going to have children. Additionally, they may be the unhappy recipients of uniformed but perhaps well-meaning lectures about how they shouldn't "wait too long to have a baby or (insert bad outcome here)".

Psychological implications of being diagnosed with infertility when a little "less young"

Women in their late 30's and 40's often have a somewhat different experience of being diagnosed with infertility. For them, the shock of an infertility diagnosis often seems to be less intense. It is fairly common knowledge that fertility potential decreases with age--thus, women diagnosed a little later in life often aren't totally blown out of the water that they must contend with this issue. Instead, they often deal with intense feelings of self-blame and recrimination. "If only I'd started trying when I was younger!" is a refrain I have heard many times, even though for these particular women, starting a family at an earlier point in life was often a difficult or impossible choice for them. In addition, women dealing with infertility in their late 30's or 40's must also endure comments from others that that they waited "too long". These women may also feel developmentally out of sync with other women their age, who now have children or have decided to live child-free.

As an aside, it seems that when a woman is in the "less young" age bracket, it is often assumed that she could have had children earlier if she had chosen to, and thus the cause of her problem is more volitional in nature. However, I suspect that many women may have had preexisting infertility conditions all along, but may have simply been unaware of it. I myself was diagnosed with infertility at age 30; but if my life circumstances had been such that I hadn't started trying until now, in my early forties, I would have no way of knowing that at least for over a decade, I was infertile. As I have a talent for self-recrimination, and seem to take it up at every available opportunity, I am sure I would be focusing on how I made the "wrong choices" right this very minute. But in reality, it would be entirely inaccurate.

No matter what your age when your infertility is recognized, it is important to be aware that the timing of your diagnosis may affect how you experience your infertility. In particular, be try to be alert for feelings of low self-esteem, isolation, and self-blame and recrimination. By better understanding those feelings from a developmental perspective, it will be easier to acknowledge what I consider to be the timeless truth of infertility--that it probably isn't anyone's "fault".

Infertility and George Washington: Integrating experiences of infertility into a life narrative

2011-03-31T18:01:00.000-07:00

It's spring break week and my family has been traveling through Washington DC and Virginia, visiting family and sightseeing, predominantly at historical sites. This simultaneous emphasis on my own personal history while learning more about American history has reminded me of the importance of creating a narrative about one's life. By telling your own story, you often integrate separate parts of your life, creating a more coherent sense of self.

Integrating your experiences with infertility into your life narrative is an essential part of understanding how it has affected you. For example, as we drove through the area of the country my mother's ancestors lived, I found myself thinking about how in retrospect, past generations of my female relatives have also struggled with infertility, although it may not have been diagnosed or treated. I also found myself wondering how surprised (most likely pleasantly) my relatives might be to learn that a beautiful, self-possessed girl born in India was now a member of their family.

In addition to my own story, I also discovered another narrative of infertility in a place I didn't expect to find it. During our visit to Mount Vernon, George Washington's home, I heard repeated references to his raising of his wife's children and grandchildren (Martha was a widow when she met George and had two living children prior to their marriage). However, I didn't hear any mention of any children he and Martha had together. My "infertility antennae" went up, and so when we got to the hotel, I started Googling. Sure enough, it seems that George Washington himself most likely suffered from infertility. There was article published in Fertility and Sterility in 2004, which can be found here, which reports that George Washington was most likely infertile due to a prolonged infection with enteric tuberculosis. Like most men of his time, he blamed his infertility on his wife. However, it seems that Martha's prior history of four successful pregnancies suggests that George Washington's own fertility was most likely compromised. Further, the article describes evidence that George Washington had wished to have children and was saddened upon the realization that this probably would never happen for him. By all reports, he loved children and enjoyed the time he spent raising Martha's children and her grandchildren.

The article's author, John Amory, also speculated on how George Washington's infertility may have affected his professional career and the development of the United States. Did his disappointment about not having any children of his own fuel his ambition and resolve? Was George Washington more motivated to nurture talented young men, thus strengthening the new country and its emerging government, to fulfill some of his own parenting needs? Although we may never know for sure, it stands to reason that George Washington's infertility must have shaped his emotional and professional life in many ways. Freud's concept of sublimation, in which unfulfilled desires are channeled to more socially appropriate goals (or in this case perhaps goals that are possible to achieve) may be relevant here.

Interestingly, the author noted that in historical and medical discussions of George Washington's life, his lack of children and probable infertility is very rarely mentioned. He theorizes that some historians may feel that discussing his infertility might "lessen" his image. However, to me, it only makes George Washington an even more impressive person. He was able to accomplish incredible things and change the course of history, all while struggling with his own feelings about not being able to have his own children--a struggle that most readers of this blog know is a profound one. In addition to being a hero and a great leader, he also has provided us with a model of resilience and coping. Despite his bad luck with infertility, he led a successful, rewarding, and incredible life. In the end, I think that is the best outcome for which we can hope--regardless of our circumstances.

Do feelings about infertility ever go away? Long-term psychological implications of infertility treatment

2011-03-21T13:17:00.000-07:00

As an infertility therapist, I think the question that I am most commonly asked is whether or not the pain from infertility ever goes away. During those dark periods during infertility treatment, it can seem as if things are always going to feel as bad as they do at that moment.

I can always offer reassurance that things will indeed eventually feel better, but I cannot say with confidence that the pain of infertility goes away completely. In my experience, people do generally go on to resolve their infertility issues in one way or the other, and lead happy and rewarding lives. Even within those lives, however, there are moments in which the pain of infertility resurfaces. I will never forget feeling that familiar, bittersweet pain and envy upon hearing a friend was pregnant--except that I myself was actually pregnant at the time! It is almost as if the pain and envy had become a reflexive response, conditioned over the years. A few months of pregnancy had done nothing to extinguish it.

The above example highlights one of the ways feelings about infertility may reemerge--through exposure to familiar situations and cues. Certain dates, times of year, people, and places may all be evocative of painful experiences, events, or realizations. Although in retrospect such painful feelings are completely understandable, they often take people off-guard if they are not prepared for them.

Another time infertility-related feelings commonly resurface is during major life transitions. For example, perimenopause and menopause bring up feelings about reproduction for almost all women, but if there is a history of infertility there may be more intense feelings about closing this chapter in their life.

A history of infertility also is known to increase anxiety during pregnancy and parenthood. Because you have already experienced things not going according to plan, you become more aware of all the frightening, albeit relatively improbable, possibilities during pregnancy, childbirth, infancy and childhood. So many times, I have seen women who had repeatedly fantasied about how happy they would be once they were pregnant become overcome with anxiety once the long-awaited pregnancy occurred. Although this is a shame, I think in a certain way it's probably unavoidable given the types of infertility experiences they had endured.

Infertility is usually a profound, life-changing experience. Studies have shown it to be only slightly less traumatic than the death of a parent and on par with a divorce in terms of the stress it produces. As a striking example, I worked with a woman who experienced infertility, but then went on to have several children. Along the way, she encountered several difficulties. One of her children had a serious, but correctable medical condition. She herself experienced medical difficulties in which her own life was hanging in the balance for months. During this time, she also unfortunately experienced a great deal of interpersonal conflict and disappointment. When I asked her which one of these situations had been the most difficult, she answered without hesitation, "Infertility."

As a silver lining, I have found that each time feelings about infertility reemerge, it is an opportunity to work through them again. This can allow you to have more closure and to better understand your own experiences. With time and distance, you can see things more clearly, and may able to resolve some of the hurt feelings of the past.

So in sum, yes, it really does get better--a lot better! But when something this profound happens to us, we can't expect ourselves not to have feelings about it for a long time to come. However, those painful moments can often often contain the seeds of future psychological growth, and thus our lives may actually be enriched.

Unpredictability

2011-03-15T07:05:00.000-07:00

A few weeks ago, when I returned to my car after work, I found an unpleasant surprise. The passenger side window of the car was smashed in, and glass was everywhere. The contents of the car were tossed about. The thief had apparently tried, and failed, to steal the built in DVD player (although he/she did succeed in breaking it--so probably trying to steal one of those things is not a good idea). Nothing was stolen from the car in the end--not my electronic toll pass, not prepaid parking vouchers, not my daughter's wallet with all of her life savings in it. It did create, however, a big mess, an expense, $2800 worth of damage to the car, and some discomfort and work for me.

During my rather cold, windowless drive on the expressway to the repair shop, it struck me that this situation felt very similar to the realization that I was infertile. When I first arrived at my car, I was in a state of disbelief. Even though what had happened was obvious, my mind did not want to accept that someone had broken into the car. "Perhaps someone just accidentally bumped the window in a freak accident," I kept thinking. However, the preponderance of evidence to the contrary forced me to accept the fact that yes, I had just been robbed, and that yes, people can be not-so-nice sometimes. The latter is a fact that even though I know it is true intellectually, I have always struggled with accepting it emotionally. I think the same is true for my infertility. Even when a preponderance of evidence suggested I had big fertility problems, I could still entertain the fantasy of somehow miraculously getting pregnant anyway--which obviously never happened, and isn't going to happen, either. I think it's taken me over a decade to accept that fact--and as those who know me can attest, I am not exactly Suzy Sunshine. Optimism is not my game. I am not a denial-prone person, and could probably use a little more denial in my life. So if even I have struggled long and hard with accepting the finality of my infertility, I think it has to be a pretty common-place event among those who naturally have a sunnier outlook.

Another facet of the break-in situation that felt similar to infertility is that it created a lot of work, delays, and expense. Despite my medical problems, I am lucky to have two wonderful children. However, those children were not easy to come by--both the adoption and IVF journeys they required involved a lot of hard work, physical discomfort and suffering, time, and money. Just like the car, it was doable. It wasn't the end of the world--but it did require marshaling a lot of energy and resources that could have gone to other things, I suppose--like my career, or learning to cook food without burning everything. But we must play the cards we are dealt, and placed in the same situations again, I would make the same choices again, even though they required hardship and sacrifice.

Once I accepted that my car was burglarized, I realized I needed some help--because I had no idea how exactly to manage the situation. I tromped to the parking garage office and told the lady working there what had happened. She sprang into action, filling out forms, and letting me use her phone to make the police report. Two other garage employees worked for a long time in the freezing cold to clean the glass out of my car. The worked endlessly on taping garbage bags to the window, which was an incredibly sweet gesture even though it blew off as soon as I had to drive 30 mph. They all introduced themselves, hugged me, and told me to come by and visit them every week at the office--they were going to "take care of me". They were all such lovely people, and I never would have met them otherwise. To be shown such kindness, after experiencing some of the less desirable parts of human nature, was wonderful. That struck me as the other thing that is reminiscent of my infertility. Because my infertility happened, I have had the good fortune to meet and work with wonderful people whom otherwise I would never have known. I include my blog readers among this list--it's been a pleasure to read your comments and blogs and get to know you a little bit.

Okay, so maybe that doesn't completely make up for getting your window smashed in, literally or metaphorically. But it really does help soften the blow.

Now, if I could just get my car back from the repair shop.....

Can psychological support groups really double your chance of conception during infertiity treatment?

2011-03-03T13:59:00.000-08:00

My father was in town last weekend, and was very excited about a clip he had recently seen on the Today show about infertility, which can be found here. He was very impressed to learn that if a woman participates in an infertility-related social support group, it doubles her chance of conception in a given treatment cycle. When I expressed skepticism, he was adamant. "They proved it at Harvard," he exclaimed! How could I argue with that?

And really, why would I want to argue with that? No one would like to believe that providing people with emotional support would fix their infertility problems more than me. Not only is this a problem I could actually do something about, but given my line of work, it would be financially lucrative if this were true. And yet, I had a sinking suspicion that unfortunately, this was just too good to be true.

Thus, I took myself took a look at the study referred to in the Today show interview. (For those of you who are interested, here is the citation: Domar, A. Clapp, D.,Slawsby, E., Dusek, J., Kessel, B., Freizinger, M., (2000). Impact of group psychological interventions on pregnancy rates in infertile women: Presented at the Annual Meeting of the American Society of Reproductive Medicine, October 5, 1998, San Francisco, California. Fertility and Sterility, Vol. 73 (4), 805-811.) And indeed, the study was performed at Harvard Medical School. The lead author, Alice Domar, Ph.D., is a very well-known psychologist in the area of infertility. And yes, the results did show the women who participated in one of two types of support groups had a conception rate of 54 and 55 percent, respectively, versus only 20 percent in the control group.

However, as is so often the case with psychological research, the results are not the whole story. As the authors of the study themselves explain, this study had some serious methodological issues that call into question the veracity and applicability of its results. The researchers had difficulty recruiting subjects for the study, and thus the sample size involved was very small--too small to conduct powerful statistical analyses or to make sweeping generalizations to the population in general. The researchers made no attempt to control for the type of diagnoses with with the women in the study were struggling--so there was no way to tell whether or not the severity of the diagnosis was a factor in treatment success. Further, because they had difficulty recruiting enough subjects, the researchers were unable to randomly assign women into the three groups (cognitive-behavioral treatment, social support group, and no treatment). In addition, they had such large rate of dropout in the control group (which received the 20% success rate) they decided to not run any statistical analyses on the results because they would not be representative or accurate. The authors concluded that it may be that psychological interventions could increase pregnancy rates, but they could not definitively prove it on the basis of this study--further research was needed to clarify the issue. And by the way, further study has not uniformly supported this finding. Dr. Domar's later studies in this area have shown that while being in support groups or mind-body treatment may increase coping skills, quality of life, and a sense of well-being during infertility treatment, it does not appear to significantly increase, much less double, pregnancy rates.

Needless to say, none of the above limitations mentioned in the study were mentioned in the Today show interview. Rather, the results of this study were presented as Harvard-endorsed gold-plated facts. I don't think there was any malice in this, but rather a good dose of naivete. It does underscore, however, how you really can't believe everything you read, hear, or see on television. As infertility patients, it is imperative for us to all become educated consumers of research. That way, we can go to the studies ourselves and evaluate them critically in order to make the best treatment decisions possible. With the internet, scientific journals and studies are now easier to obtain than ever. Although I did take several research and statistics classes in graduate school, anyone can read and understand the author's descriptions of the problems with the study in question.

I must add that I am a big fan of support groups for infertility. I think that they can provide a great deal of information, camaraderie, and support and I would encourage everyone struggling with infertility to consider joining, creating, or leading one. I just don't think we can expect that in doing so, pregnancy rates among the group members will double. As I've said before, I have a sneaking suspicion that your reproductive system, unless under extremely stressful conditions, doesn't care too much about your unconscious conflicts or how you feel. That doesn't mean that you shouldn't care either, though--and that's where getting enough emotional support is so important, whether it helps you get pregnant or not.

The role of anxiety in infertility treatment

2011-02-24T09:47:00.000-08:00

Anxiety is an unavoidable part of infertility treatment, and it is probably one of the main reasons that the process often is so traumatizing. After all, there are so many opportunities for worry during every treatment cycle, from successfully being cleared to begin treatment, response during treatment, embryo fertilization and survival, and of course, the outcome of the pregnancy test. Many of these things are out of our realm of control, and worrying about how it will all turn out is sometimes all we have left to "do". In addition, treatment cycles usually stretch out over a month or more, with long periods of time in which we must simply wait to get more information. Thus, much of the time, we look at the anxiety we experience during infertility treatment as something we must manage and work around, rather than something to which we need to directly respond.

However, there are times when anxiety can play a positive role in infertility treatment. Anxiety can function as an important signal that there is something in the situation that is not safe or good for us. In such cases, if we don't respond to our anxiety, we can be missing opportunities to improve our situation.

From an evolutionary perspective, anxiety functions as a protective mechanism. Because we must take in a large amount of information from our environment quickly, we often respond to threats on an emotional, rather than a cognitive basis. As soon as a threat is perceived, our emotional response of anxiety and fear, such as "Oh no! Hungry tiger over there!" quickly helps our bodies respond to the situation, providing the energy to do what must be done to ensure our survival (in this case, running away).

Although most of us no longer spend lots of time in the jungle keeping our eyes out for tigers, the protective mechanism remains the same. Thus, if during the course of your infertility treatment, you suddenly find yourself experiencing intense anxiety, I think it is important to take some time to figure out why. Did something just happen with your treatment that you found concerning, even if your doctor or nurse didn't? If so, it may be important to investigate this further--it has been my experience that even the best of medical professionals can occasionally miss a detail that might turn out to be very important in the case. For example, a friend of mine became anxious during her IVF cycle when she noticed that the time of retrieval, her lining was only 5.5 mm. She raised this issue with her RE, but he wasn't concerned about her lining and did the transfer anyway, which resulted in a chemical pregnancy. Her anxiety about her lining persisted, and she decided to get a second opinion. During that consultation, the new RE agreed with her concerns about her lining. As she pursued treatment with him, it turned out that she indeed had huge lining problems--causing her cycle to be canceled twice until they finally figured out the winning combination of medications to get her lining to the proper thickness. However, once her lining was good, she was able to get pregnant and carry her baby to term.

I think another important type of anxiety that often goes overlooked is rooted in the physical, body sensations that women often have during infertility treatment. Although I think most doctors don't put much stock in these perceptions, I have found that women who are infertility treatment tend to be so aware of their bodies they can often tell that something is awry before it appears in lab results or on a medical exam. For instance, they may be able to discern that their bodies aren't responding to medication in the desired way. Also, on several occasions I have observed that women have been able to sense when an early pregnancy isn't going well, even before their HCG levels start dropping. If you are in treatment and you have anxiety due to the persistent sense that your body is just not feeling right, I would encourage you to report that to your doctor and investigate it further if need be.

In sum, although anxiety during infertility treatment is usually never pleasant, it can sometimes provide us with useful information. Learning to discern whether or not an anxiety signal is a response to a potentially threatening situation, or whether it is in response to merely feeling out of control, is an important aspect of managing--and surviving--infertility treatment.

Disclosure and secrets in infertility treatment: or how I became a sneaky liar

2011-02-17T07:24:00.000-08:00

Some weeks ago, a few readers asked me to discuss the topic of disclosure in infertility treatment. This is an extremely important topic, and yet I have found myself procrastinating in terms of writing about it. I think this is because I myself have struggled with the decision of how much, and to whom, to reveal about my infertility treatments and decisions. With both disclosure and secrecy, problems arise, making a clear-cut choice between the two options difficult at best.

As I have written about previously here, I was actively involved infertility treatment for several years before we adopted our older daughter, and then again a few years later.

When I was first diagnosed with infertility, I was fairly open with my friends and coworkers about my situation. The decision to do so was concordant with my personality and outlook on life in general—I have always lived my life as an “open book”. At first, it was great, as I could talk about my infertility whenever I wanted to, and I had lots of support from the people around me. However, as things began to drag on, and treatment cycle after treatment cycle failed, I started to regret my decision to be open. It felt like it was my responsibility to inform the many interested parties that my cycle had failed—again. Each time it happened, I dreaded this process of going down the list and making those calls (no Twitter back in those days!) more and more. After my first miscarriage, these calls were downright excruciating. Further, as my friends and coworkers were predominantly women in their late twenties and early thirties, they were all starting to get pregnant. Consequently, many worries and discussions about how to tell “poor Lisa” the news ensued. Sometimes I would hear about their pregnancies through the grapevine, sometimes I would guess, and sometimes I would be told directly--occasionally with kindness and finesse, but often not. As you would probably expect, after a certain point, I had difficulty coping with this situation, and I withdrew from many people who were otherwise lovely friends and acquaintances.

Years later, when after adopting, I decided to return to infertility treatment, I knew I had to do things differently. So this time, I decided to consciously limit the number of people I told about my plans to two close friends, and my parents, and my brother and his wife. If I didn’t absolutely need the emotional support and/or instrumental help of the person involved, I didn’t tell them. I thought that this would protect me from having to provide disappointing news again. In addition, I wouldn’t have to hear others' opinions, informed or not, about my treatment decisions. As I already had an adopted daughter, no one suspected that I would be crazy enough to try infertility treatment again—so I didn’t get many questions, either.

I was surprised to find that not disclosing what was going on with me was more difficult than I had anticipated. To prepare for my treatment, I had to do a two-month course of Lupron Depot, which threw my body into sudden and severe menopause. I was sweating, forgetful, and miserable, but I couldn’t really tell anyone that—so I had to make creative excuses about why I kept turning red all the time. On occasion, I found myself telling lies about where I had been, or why I couldn’t do certain activities. But perhaps more significantly, I found that if I wasn’t able to talk about what was really going on with me, I basically felt I had nothing to say to people about myself. I didn’t feel good about lying to people, and I didn’t trust myself not to slip some detail into the conversation that would only make sense if you knew the whole story. I felt tongue-tied and I’m sure others noticed my awkwardness. Thus, I became somewhat withdrawn again, from an equally lovely group of friends and acquaintances.

This reticence continued into my pregnancy, when well into the second trimester I found it difficult to disclose that I finally was pregnant. When my precocious young daughter figured out what was going on, she had no such qualms though, and her first step was to share the news at her preschool’s Show and Tell day—and thus I was “outed”. Of course it didn’t help that no one believed that it was possible, so both my daughter and I were met with shock and incredulity at these disclosures. One colleague of mine heard that I was pregnant through a mutual client, and refused to believe him, instead calling me in a panic because he was concerned that our client had suddenly become psychotic.

My withdrawal and reticence began to have a negative impact on my relationships. Several people were hurt that I hadn’t told them what I was going through, or informed them sooner about my pregnancy. I am fortunate that after I explained to them what had happened to me regarding disclosure in my first years of infertility treatment, they all forgave me. To be honest though, one of those friendships really never did recover, and I still feel sad about this.

In sum, I am not sure which was the best approach—telling, or not telling. I don’t think there is a “right answer” when it comes to disclosure. Rather, I think you have to pick your poison—is it more important to you to feel like you can be honest with those in your lives? Or does it feel more important to protect yourself from the reactions and emotions of others regarding your infertility treatment? If you don’t tell people what is going on, will you have other ways of getting the emotional support you need to survive the stress of infertility treatment? If you do, and they don’t handle this information well, will your relationships be able to weather the storm?

As you can see, I’m afraid I have more questions than answers when it comes to the issue of disclosure in infertility treatment. I’d love to hear your thoughts and experiences, and as always, if you have any questions or suggestions, please let me know. Thank you for reading!

To "POAS" or not to "POAS": psychological implications of home pregnancy tests in infertility treatment

2011-02-10T09:06:00.000-08:00

As every person whose ever done an infertility treatment cycle knows, the two weeks spent waiting to see if it worked or not are often excruciating. For the woman involved, the constant self-monitoring of her physical sensations can be overwhelming. Was that a cramp? If so, was it a "good cramp" or a "bad one"? Are my breasts hurting? Do they hurt more than yesterday? And what about that toe-itching? Does that mean anything? Add into the mix the fact that infertility medications usually taken during the two week wait, like progesterone, have their own slew of pregnancy-mimicking side effects, and that early pregnancy symptoms are themselves notoriously fickle, coming and going with no rhyme or reason--and you've got all the makings of a very stressful time.

Enter the home pregnancy test--loved by some, hated by others, and feared by most. Some women swear by them, saying that they give them the soonest possible information--good or bad. To these women, tolerating the anxiety of not knowing is so difficult that testing seems like the best option. Others regard them as "evil"--whom among us has not seen them referred to as the "evil pee stick" online? These women argue that "POASing' (peeing on a stick) can drive you crazy--test too early, and you've convinced yourself that you aren't pregnant when perhaps you are. If you test at the right time and get a negative result, it might be inaccurate. Regardless, even with a negative, you will still be hoping it is wrong, and then will be just as crushed when the clinic calls to say that your pregnancy test was negative. And regardless of what you feel about the idea of taking HPT's during a treatment cycle, we all share the experience that the few minutes it takes for the test results to appear are some of the longest-seeming minutes of our lives!

From a psychological perspective, is taking home pregnancy tests a good idea or a bad one during infertility treatment? To me, there isn't one right answer to that question. Rather, I think it depends on what I like to call your "defensive style"--the usual methods you use to cope with stress and anxiety.

When POASING may be helpful

If you tend to deal with stress by thinking about the stressful situation frequently, you are probably a person who, for better or worse, tends to experience your anxiety consciously. You may repeatedly go over the situation in your mind, trying to come up with a solution--even when there really isn't one sometimes. You may tend towards impatience, and dislike surprises or the feeling of being taken off guard. In this case, I think that you may find using home pregnancy tests (with a few caveats, listed below) will be helpful in managing your emotions during the two-week wait.

When POASING might not be for you

If you tend to deal with stress by focusing on things other than the stressful situation, and if you find thinking about or talking about them to be difficult, you may want to avoid home pregnancy tests. For you, they might just stir things up too much,causing you to feel unnecessarily traumatized. You may be better off dealing with the results, whatever they are, just once, when you hear them from the doctor's office.

If you are going to POAS--POAS "smart!"

If you find that you are the type of person who may want/need to use home pregnancy tests, I offer the following advice to minimize the chances of getting inaccurate information and the level of emotional turmoil involved. My first suggestion is that before you go to the drugstore or start running to the bathroom, you need to decide, in advance, what your POAS strategy will be for this cycle. What is more comfortable for you--testing as early as is feasible to get information as soon as possible, or waiting to make sure you don't get a false positive or negative? Figure this out, make a plan, and stick to it. Decide what day you might start testing, and how you will proceed depending on the type of results you get. Some women feel most comfortable waiting until the morning of their beta to test--others may prefer to start as soon as possible.

You also must promise yourself that no matter what the results are, you will not stop your medications, or stop following your doctor's orders, until your official test results come back--no matter how hopeless you feel the situation may be. Even if there is only a slim possibility that a home pregnancy test may be wrong, it still exists--and you don't want to have to live with lingering regrets about such a decision later in life.

If you are in the "start as soon as possible" camp, then keep in mind that if you took an HCG trigger shot, it can give you a false positive as the HCG remains in your system for several days until it washes out. So you probably need to wait at least 10-12 days from when you took your trigger shot to start testing. (Although, as a client of mine pointed out, you could POAS every day after the trigger shot, and wait for it to turn negative, and then if it starts turning positive again, you know you might be pregnant. While scientifically interesting, this method is definitely not for the feint of heart!)

Regardless of when or how often you decide to test, you should use a consistent method of urine collection and test administration in order to assure the most accuracy in the results. Take the test at the same time every day--most people find their first morning urine to have the highest concentration of HCG. If your urine isn't very concentrated, you may have to "hold it" for a while and test several hours later in order to get accurate results. Some women find peeing in a cup, and then holding the test stick in the cup for the number of seconds designated in the test instructions, to be more accurate.

Also, please be aware that different brands of pregnancy tests have different levels of sensitivity. If you are wanting an early result, you will probably need to buy one of the more sensitive tests. A list of tests and their HCG sensitivity levels can be found at several sites on the internet, including here.

Regardless of whatever strategy you choose, please keep in mind that a pregnancy test is just one piece of data from one point in time, and it may or may not tell the whole story. Like anything else in life, there are emotional risks involved in using them--but if you keep to your strategy, stay on your medications no matter what, you will hopefully find that there will be no lasting damage to your psyche.

An inspiration for the hard times during infertility treatment: Ernest Shackelton, Antartic explorer

2011-02-03T14:18:00.000-08:00

During the dark days of my own infertility treatment, I came across a biography of the life of Ernest Shackelton, an early 20th century British explorer who attempted to cross the South Pole, but failed to due so, due to a series of bad luck and unforeseen events. Although he was forced to abandon his original goal, he performed another even more spectacular feat--despite the most extreme circumstances, he was able to ultimately lead his men to safety, without the loss of a single life.

In the story of his journey, I found numerous parallels between his experiences and those of individuals forced to take the journey of infertility treatment to try to create their family.

For those of you unfamiliar with the story, I am quoting a summary from an article by Charles Chappell (2001; link to full article can be found here):

"On December 5, 1914, Sir Ernest H. Shackleton and 27 men under his command sailed from South Georgia Island in the South Atlantic aboard the boat Endurance. Their goal was to land on the Antarctic continent and become the first to cross it. The North Pole had been reached in 1909; the South Pole, in 1911. Shackleton, a veteran of Antarctic exploration who had been knighted for his earlier expeditions, felt that crossing Antarctica was “the last great Polar journey that can be made.” He named his endeavor the Imperial Trans-Antarctic Expedition.
Shackleton and his men failed utterly at the expedition’s stated goal; they never even set foot on Antarctica. Yet the courage and determination they displayed have become legendary.
In January 1915, before they could reach the Antarctic coast, their ship became trapped in the pack ice of the Weddell Sea. For nine months, they and their ship drifted helplessly with the ice. Then, in October 1915, currents and wind drove massive plates of ice in on the Endurance,crushing it. Members of the expedition were forced onto the ice floes surrounding the ship.
They salvaged three lifeboats and whatever equipment and provisions they could extract from the tangled wreckage of the ship before it sank.
The ice became their home for the next six months. Attempts to move their provisions and gear dozens of miles over the ice to land were frustrated by gaps between floes and impassible ridges of ice blocks pushed up against each other by currents and winds. As their food supplies dwindled, they were forced to hunt whatever penguins and other sea life they could find. Although the men initially hoped that the drifting of the ice would carry them toward land, in time it became clear that they were drifting northward toward the open ocean. In late March,1916, cracks began splitting the floe into ever-smaller pieces. On April 9, they were forced to take to their boats in an attempt to reach one of a few small islands off the Antarctic coast. For seven sleepless days and nights, they battled the sea ice and the ferocious weather of the Southern Ocean, finally landing on remote, uninhabited Elephant Island.
Shackleton and five others left that island eight days later in the most seaworthy of the boats, the James Caird, to get help at South Georgia Island, a staggering 650 miles away.
Battling towering waves and weather that made navigational sightings almost impossible, they reached South Georgia 16 days later, only to come ashore on the uninhabited side of the island, opposite from the whaling stations they sought, and with the Caird’s rudder gone.
With no choice but to travel on foot, Shackleton and two of the other men set out to cross the mountainous, glaciated, and uncharted interior of the island. On May 20, 1916, they walked into the whaling station at Stromness Bay. Although the three men on the other side of the island were rescued the next day with help from the whalers, it would be four months and three attempts before a Shackleton-led rescue party succeeded in making its way through the sea ice to reach the remainder of the men at Elephant Island on August 30, 1916. Amazingly, after almost two years of danger and privation, not one of the expedition’s 28 members had been lost."

As you can see, Shackelton and his men did not have it easy! Numerous times, they were forced to change their goals; to endure extreme physical discomfort and deprivation; and to traverse unmapped territory; and to depend on strategies that had at best limited chances of success. Although the conditions Shackelton and his men faced were undoubtedly more extreme, many people undergoing infertility treatment deal with similar challenges. Sometimes, we must abandon our goals and hopes of having children the easy way without medical assistance, or having genetically related children. Also, infertility treatment involves its own physical discomforts and deprivations, and the outcome is never guaranteed.

To me, though, the most salient lesson of Shackleton's experience is that even though he did not achieve his original goal, he did the best he could with the set of circumstances (and they were really lousy circumstances) he was given. He used every bit of his physical, intellectual, and psychological abilities to survive, and to make sure everyone else on the expedition did too. He took great risks, made profound sacrifices, and his accomplishment, the survival of his entire team, still seems nearly impossible. For this, he is rightly considered a great man and a hero.

Although infertility treatment is necessarily more private than a polar expedition, I see similar heroes in my clinical practice with great regularity. And like Shackelton, who unfortunately did not view himself as a success (and in fact died of a heart attack during the launch of his "comeback" expedition), too often my clients do not themselves recognize the magnitude of what they have done. Despite the outcome of their treatments, they have also used all of the intellectual, physical, and psychological resources to give themselves the best chance of success. They have come up with innovative solutions to the difficult circumstances in which they find themselves. They have demonstrated profound endurance, and have tolerated physical and emotional conditions that are inhospitable to say the least. And so in my book, they are heroes too--no matter how things work out.

I think it's important to try to recognize all the different ways you yourself have been brave and heroic in your own infertility journey. This can be particularly helpful during the discouraging and dark moments, and can give you the strength to move forward. And I suppose it's always comforting to remember that at least one other person, Ernest Schackelton, didn't always have smooth sailing either.

Infertility and third party reproduction in the public spotlight: psychological implications

2011-01-20T11:55:00.000-08:00

I think it's safe to say that infertility and third party reproduction is in the public eye now more than ever. For instance, the reality show Guilana & Bill has followed the celebrity couple Guilana and Bill Rancic through 2 IVFs, one ending in miscarriage and another ending in a BFN. Numerous celebrities have announced the births of their children created through some form of third party reproduction. News reports, articles, and documentaries about the growing practice of international egg donation and surrogacy have been published and aired. It seems that when it comes to infertility treatment and third party reproduction, almost everyone has a strong, if perhaps not well-informed, opinion.

In her blog, Dawn Davenport at Creating a Family wrote a really wonderful post, found here, about the media coverage of and public response to Nicole Kidman and Keith Urban's daughter's birth via a gestational carrier. In it, she excerpts some of the many negative comments that can be found on the internet about their use of a gestational carrier. As you can imagine, some folks out there in cyberspace are not supportive of Kidman's and Urban's decision, suggesting that Kidman didn't want to ruin her figure with a pregnancy, or decrying the use of a gestational carrier/surrogate as dehumanizing or morally wrong.

As the spotlight shines on our little corner of the world, I find myself wondering about what all this attention, both positive and negative, means psychologically for individuals experiencing infertility in their own, less public lives. On the one hand, I think that increased public awareness of the issues involved in infertility could be beneficial to those currently experiencing it. Perhaps seeing a couple on television deal with a miscarriage and failed treatment cycle could help watchers become more empathic to their friends, family members, and neighbors who are in the same situation. Also, if the public increasingly understands infertility as a medical condition, there may be more public support for increased health insurance coverage.

However, I think that the negative commentary now floating around out there adds a new wrinkle of difficulty to the already complicated psychological terrain of infertility. The negative comments people feel compelled to make about the family building choices of celebrities seem to fall into two categories. The first is that somehow the celebrity him or herself is personally to blame for their situation, rather than having a medical condition. She waited too long, she is too selfish and vain, etc. The second category has to do with the idea that the celebrity is somehow circumventing God's will or fate--e.g., if it's meant to be it will happen, so using IVF, or a surrogate, or whatever, is therefore wrong.

Although I always suspected that some people felt this way about infertility treatment and the choices it involved, in my own personal and professional life I've never had anyone express these criticisms to my face. Perhaps they were thinking it, but I didn't have to deal with it explicitly. Not so anymore. Yesterday, I read an interview in which Guiliana Rancic repeatedly defends herself against public commentary (presumably from people she has never met) that she has caused her infertility by being too thin. This struck me--I mean, it's bad enough to figure out what to say to your insensitive Aunt Maisy who always suggests you just need to relax, or maybe it's just "not meant to be", but to have to start arguing with people you've never met? Although Ms. Rancic is the star of a reality television show and thus has opened up her life to public opinion, it is hard not to take the negative comments made about her situation, or those of other celebrities, and apply it to ourselves, however obliquely.

Of course, it is perhaps only a minority of people out there in the world who have such intense negative feelings about infertility treatment. But with the cloak of anonymity and the ability to publicly express themselves instantaneously at the touch of a button, they can make a big difference in the psychological climate surrounding infertility--and I would argue it's not a good difference. If people person are already inclined, albeit unfairly, to blame themselves for their infertility (and most infertile individuals struggle with this from time to time) negative comments such as these can be used to support this erroneous belief. Fodder for self-criticism is, after all, only a short internet search away.

Although it is possible to avoid reading negative opinions and comments about infertility, it does take effort. And I feel that even if we ourselves never read a word of this stuff, other people do--and this changes the emotional landscape in which we find ourselves.

I am very curious about others' experiences in this regard. I would love to hear your thoughts and stories about how the increase in news coverage around infertility has (or hasn't) affected you. Please leave a comment if you can! And as always, if you have any questions you think I can answer, or any topics you think it would be helpful for me to address in my blog, I'd love to hear from you.

Thanks for reading, and have a great ICLW!

"Other people's children": Fears about adoption and donor gametes

2011-01-13T11:44:00.000-08:00

During infertility treatment, it sometimes becomes evident that in order to have a family, one or both of the prospective parents may be unable to contribute their own genetic material to the creation of their future child. Of course, this is a big loss, and something to be grieved over time. As clients move forward through this grief and consider their alternatives, they often express the same fear--that they will be unable to have a fully satisfying parenting experience because they will be raising "other people's children".

This is a complicated issue because when you adopt, or use donor eggs or sperm to create your family, in a very basic, concrete sense you actually are raising "other people's children". In fact, there are an additional one or two "parents" swirling around in the mix. This causes us to reconsider how we define what makes a "parent", and what is necessary for the parental connection to occur.

I would argue that it is indeed possible to have a fully satisfying parenting experience raising a child who genetically originated from other people. In fact, research has shown that most parents who do adopt or use donor gametes to build their family are very satisfied and fully involved parents, and are happy with their choice to do so. But I would also argue that it is a different parenting experience than having and raising a genetically related child.

Being aware of and comfortable with genetic contributors of our children seems to be emphasized in more adoption community than it is in the infertility world. Indeed, open domestic adoptions, in which there is some contact with the birth parents, are very common. With children created through third party reproduction, it is more possible to not disclose the genetic origin of these children to others, even including the child involved.

In both the infertility and adoption literature, this subject has been discussed in depth. To this discussion I would like to add, however, two points that I have not seen mentioned with frequency--the psychological constructs or images the parents develop about their child's genetic origins. The first concept I would like to discuss is how the expectations we develop based on genetic relatedness and family resemblance can affect our parenting experience. From a psychological perspective, when one parents a genetically related child, there is at least the possibility of explaining things about that child from a genetic viewpoint. That Junior has his father's eyes, his mother's laugh, and his Uncle Charlie's love of striped socks, may or may not in reality be true--but these are the hypotheses we create, seemingly reflexively. When parenting a genetically unrelated child, all bets are off, especially if little is known about the genetic parents, as in the case of international adoption, or using anonymous egg and sperm donation. If my adopted daughter, about whose biological parents I know nothing, misbehaves, is it something I did? Is it her genetically-endowed temperament? Is it a mismatch of her environment, which includes me, plus genetics? This difference adds another layer of complexity to the parenting situation.

Although this thought process may seem worrisome to prospective parents, I think in reality it is often found to be beneficial, because it allows you to view the child with an open mind, without as many preconceived notions. I actually find this process a wonderful part of parenting my daughter. It's like having Christmas everyday--without having a genetic template with which to evaluate her behavior, appearance, and characteristics (again, which may or may not be true)--she is always a surprise to me. Every day I learn something new about her. I am sure that her beauty, outgoing personality, charisma, and social skills are genetic gifts from her birth parents and not environmentally endowed from me, and I am constantly amazed at how well she navigates complicated social terrain. I am surprised she to see she can learn to spell so easily but memorizing her multiplication tables for her is difficult and seems unimportant. I am never quite sure what she will do next, good or bad. Without prior assumptions based on genetics or family resemblance, we have more freedom to be more creative in learning about each other.

This isn't to say, however, that I don't have my own inner constructions of what her genetic parents may be like. Indeed, this the second point I would like to discuss--the way in which psychologically the genetic parents may be present in the parenting experience. Whether or not the child's genetic origins are disclosed to anyone else, it is clear that the parents know the truth. Thus even in the cases where parents know little or nothing about the biological parents, they often develop a psychological image of what these people are like. For instance, I have an idea that my daughter's biological mother was much like my daughter--beautiful, outgoing, and a bit of a risk taker. In my fantasy, it is easy to see how she got herself into trouble, but also how in the end she tried to do the right thing by making the difficult decision to give my daughter up for adoption. Whether or not this fantasy in any way resembles reality (and we'll probably never know if it does), it does impact my parenting experience. For instance, I may worry more about her getting pregnant as a teenager, or feel the need to set more limits with her. When the time comes, my reaction may have little to do with the reality of what my daughter's predilections are in this department.

I have often seen this same phenomena occur with parents whose children were conceived with egg and/or sperm donation. With the little information we have about anonymous donors, we can construct similar types of fantasies about our child's genetic origins. Thus, the psychological parenting experience necessarily includes these other genetic parents.

Again, although this might sound intimidating to some at the outset, in reality, it usually isn't a problem, as long as the parents can acknowledge this and feel comfortable with it from the outset. Although it may create a somewhat different parenting experience, in no way creates an inferior one.

As to the fundamental question of whether or not we can fully love and attach to "other people's children", I would like to offer a personal vignette about my first night as a mother. We first took custody of our daughter, in India, when she was three months old. A week before she came into our care, she had been recently discharged from the hospital because she had developed a very severe case of pneumonia, in which her lungs collapsed and she went into congestive heart failure. Miraculously, she survived this three-week ordeal, but when we were given custody of her, she was extremely thin--only 7 pounds. The first day we had her, I realized she was wheezing and breathing too rapidly. A doctor's visit and x-ray quickly turned into an emergency hospital admission, and we were told she had either RSV or pneumonia. We were placed in a rather dirty public ward of an inner city Indian hospital. She got an IV and was placed in an oxygen tent, and I was terrified. I didn't know anything about taking care of babies, particularly an unfamiliar, sick, and frightened one (by the way, every time she took a look at me, she started crying in fear). I recall sitting on the floor, which was covered in old newspapers for some reason, crying on my cell phone to my mother back in the USA. Then I realized I had to get myself together. This little baby was my responsibility--there was no one else who was going to do it. At that point, I went into full mother-protection mode--managing her care as best I could, calling doctors in the USA for consultations, and yelling at the nurses who didn't want to wash their hands between patients that if they wanted to touch my daughter, they needed to use my hand sanitizer first. Although they seemed irritated by this request, they did comply. I didn't eat, I didn't sleep, and I stood guard over her day and night. And there was absolutely no thought that this was really someone else's child, because there was no room for that. She was my child because she was my responsibility.

By third day of my daughter's hospital stay, she looked at me and smiled. I smiled back. I tickled her, and we both laughed. Even the dirty-handed nurses laughed. I was filled with a rush of profound love, and I like to think she felt the same. I tell clients all the time that the fundamental thing that creates a parental connection with a child isn't DNA--it's time spent with and caring for that child. The more you do it, the more attached you are going to be to each other. It's really that simple.

So although people worry that parenting "other people's children" is going to somehow be problematic, in reality, this very rarely comes to pass. Although it will be a different type of parenting experience, it still provides rewards in abundance.

Climbing up the mountain: Infertility treatment from the long view

2011-01-06T19:10:00.000-08:00

A few months back, a client and I created a metaphor that I feel captures the experience of infertility. In this metaphor, the task of building a family is akin to climbing a big mountain. This mountain is criss-crossed with thousands of different paths and passes of varying levels of difficulty. Most women are able to follow an easy path, without much of a climb. But for those of us struggling with infertility, the easy path is blocked. Instead, we find ourselves assigned to one of the paths less traveled. All of these passes are harder than the standard path, but some of them are harder and longer than others. In many cases, we must climb the mountain without seeing any evidence that the summit is in view. We may climb for a while, and find that yet again our path is blocked, forcing us to change course, often with great difficulty. We may be lucky enough to find others with whom we can climb alongside, and that makes the journey easier. Conversely, we may find that we are forced to climb alone.

At times, the climb can be unpredictable. The path can become incredibly steep and rocky, and the weather can change for the worse. Occasionally, something terrible happens and there is an avalanche. Sometimes, we make the difficult decision that the cost of climbing the mountain is too high, and we make our way back down--and find another mountain to climb.

Usually, however, if we keep climbing, the path eventually clears and becomes smooth, and the sun starts shining. The top of the mountain, with its beautiful view, comes into sight. We are most likely quite changed by our journey--hardened, seasoned, matured, and incredibly grateful to have made it to the top.

As someone who's spent a lot of time on this mountain, both personally and professionally, I've observed that if someone is really determined to have children, then they will make it over this mountain, no matter what. It may take more time than they'd hoped, and they may have to change course more than once to surmount the obstacles before them. But mainly, they just have to keep climbing.

However, during the climb, it is very difficult to feel confident that it's all going to turn out alright in the end. After setbacks occur, we can come to feel that nothing is ever going to get easier, and that bad outcomes are inevitable. It's hard to realize that even though it is not in plain view, the top of the mountain is there waiting for us. At these points, we must use our courage, and the support of others to help us keep going.

The client with whom I collaborated on this metaphor, after a long and difficult journey, recently found her own short-cut over the mountain, just when all hope seemed lost--a true miracle. But even without such a dramatic miracle, we can still climb to the top. Despite everything, no matter how you get there, or what path you end up taking, the view from the top is the same. Perhaps, if you've been forced to take a longer and more difficult path, you will appreciate the view that much more.

Stupid $%^! my doctor says--clinical insensitivity and infertility treatment

2010-12-30T13:18:00.000-08:00

A few weeks ago I had to go to a doctor for a minor gynecological procedure. I had never met the doctor performing the procedure before, and so I had to briefly go over my infertility history with him. I was rather surprised when he told me, in a jovial, joking manner, that I was obviously "really, really, fertility challenged"--and fact, he mentioned had another term for women like me, but he couldn't use it in polite company! He thought this was hilarious. He then proceeded to comment upon and mock my c-section scar ("Of course you had a c-section--you just can't do anything the easy way, can you?") He also found fault with the fact that both of my children have their birthday in the same month, although since my older daughter is adopted, I hardly see how I could be held responsible for that. It's not as if I received a call from India, 9 years ago, with someone saying, "Hi, you don't know us, but we are young and in love. Do you think we should have unprotected sex or not?"

In any event, what was perhaps most shocking to me about this one-sided conversation is that this doctor, in the course of his work, deals with women struggling with infertility all the time. I would have expected a bit more sensitivity and tact. This doctor seemed to have absolutely no awareness that my medical condition wasn't merely fodder for his jokes--he just seemed thoroughly amused with himself. In addition, he and I didn't have a prior relationship in which he could sense that "joking" around with me about this was okay. A decade or so after this all started for me, my feelings about my infertility are much less intense and raw than they were, but he had no way of knowing that. I could only imagine that if I ran into this doctor several years ago I would have left his office devastated instead of as I did, merely annoyed.

After my appointment, I started thinking about all the examples of clinical insensitivity that I've heard about in my practice lately. I wish I could say that insensitive comments from medical professionals, like the ones I received, were a rarity, but in fact, they are not an unusual occurrence. One common type of insensitivity I've heard from several clients about different RE's is that when the client does not respond as hoped to a given medication or protocol, they are told they are "stubborn" or "misbehaving". Most women find these comments upsetting because they imply that somehow, the women have conscious control over how their bodies are responding to treatment, tapping into deep-seated feelings that they are somehow to blame for their infertility. Rationally, we all know that isn't true--if it were in any way possible to control how our bodies respond to infertility treatment, we would have already done so and had success. But hearing this idea from a doctor, even in an attempt at humor, gives it a little more weight.

A client of mine has graciously allowed me to share another example of clinical insensitivity. She had seen another psychotherapist for different clinical issues, and asked for feedback regarding them during the termination session. Instead of providing her with any, the therapist told her that she needed to work on her feelings of sadness and anxiety because they could be causing her recurrent miscarriages, rather than any underlying medical condition. (Just to be clear--there is no clinical study that shows that negative feelings, such as sadness and anxiety,are a definitive cause of miscarriages.) To her credit, my client fought back, asking the therapist if she believed that her negative feelings caused her miscarriage due to chromosomal abnormalities. And how did the therapist explain her first miscarriage, which occurred when she was elated about her first pregnancy? The therapist refused to back down or let my client off the hook, insisting that her feelings of sadness and anxiety "couldn't have helped" the situation. Again, the implication that my client was somehow to blame for her miscarriages was unavoidable. Needless to say, the treatment did not end well.

In preparing to write this post, I have struggled to come up with a cohesive explanation of why these situations might occur. But to be honest, I'm a little bit stumped. In the case of my doctor, I had such limited contact with him that I could not get any sense of his psychological motivations for acting in this way--except for the idea that perhaps, he was also someone who could be referred to by a term that could not be used in polite company. In situations where RE's tell patients they are "stubborn" or "misbehaving", I imagine it may be some of their own feelings of powerlessness and frustration coming through. Presumably, they really want to help their patients, and when they can't, it probably makes them feel powerless and bad about themselves too. So they might try to deflect these feelings by "jokingly" implying that it's the patient's fault, and not their own.

As for my client's experience with her former therapist, I again find myself hard-pressed to rationally explain that therapist's behavior. Perhaps she is uneducated about infertility and recurrent pregnancy loss, or perhaps she was angry at my client for terminating the sessions. Not knowing her, or more of the surrounding context, it is impossible to say.

As a clinician myself, I'm sure I've unknowingly said many stupid and insensitive things, although I like to think that I am trained to watch for people's nonverbal responses to what I say. If I see the eyes widen, or a lip quiver, it is my usual practice to inquire about these responses. But more importantly, I would hope that when I do inevitably put my foot in my mouth, that someone would tell me that what I said was painful, stupid, and/or inappropriate. I think most clinicians, whether they are in the medical or psychological field, feel the same way. That is why I very much admire my client for her responses to her former therapist--even though in that case, they didn't produce the desired response.

If you find yourself feeling hurt or upset by a doctor or nurse's comments about your infertility, I would urge you to discuss this with him or her. Most often, the clinician in question is going to be very understanding and apologetic. If during the course of that discussion, they are unable to acknowledge how their comments could have been viewed as hurtful or insensitive, then I think that may be a cause for concern. If the same type of comments happen repeatedly, you may need to think about making a change. It has been argued that individuals experiencing infertility often have a heightened sensitivity to comments by others. Even so, if a doctor or healthcare professional feels the need to habitually make upsetting comments to you, you can be pretty sure that it's not you--it's them.

Infertility and the holidays: Misery loves company?

2010-12-20T18:43:00.000-08:00

Although it differs from person to person, I think it's safe to say that experiencing infertility generally does not make the holiday season easier. This year, I've read many excellent blog entries and articles that discuss this issue and offer suggestions for how to handle the holiday blues, so I won't reinvent the wheel here.

I do, however, want to add the following perspective from my vantage point as a psychologist--the holidays aren't just hard for those struggling with infertility. In fact, they seem to be hard for almost everyone! Do you know how my colleagues in my office suite and I refer to the month of January? We call it, somewhat affectionately, "money time", because in first week of January, the phone literally starts ringing off the hook with new clients requesting appointments. It seems that all that togetherness, gift buying, and socially-imposed merriment is just the thing that pushes so many of us right over the edge and into a therapist's office.

Now, I am the only one in my office suite who specializes in infertility, and yet all the therapists, with their various areas of expertise, are equally busy in January. It seems that the pressures of the holiday season affects people with all different kinds of issues and from all walks of life. So although feelings of infertility may be making you miserable at the holidays, you will definitely not be alone in your suffering. It may seem like a perverse comfort, but chances are good that if your infertility wasn't upsetting you this holiday season, there would be something else that would.

I can think of at least two culprits for all this unhappiness. The first is the societal, and often familial expectation that we should be happy during the holidays. The story we are told from a very young age is that if you can somehow just inculcate the right holiday spirit, you will be able to transcend the difficulties in your life, at least for a short period of time. Although this does sometimes happen in real life, I don't believe it is actually the norm that so many holiday-themed movies would suggest. When people find that no matter how hard they try to have the right holiday spirit or frame of mind, they still can't feel better about problems that they have, they feel a sense of failure. (This is the same emotional principle that causes so many people diagnosed with infertility to become distressed--despite all their best efforts, they still have not yet achieved their desired results.) The feelings of failure, combined with the upset about whatever they were trying to transcend in the first place, can often cause people to become sad, depressed, and anxious.

Another reason why the holidays can be especially upsetting has to do with the anniversary reactions they provoke. As with any trauma or loss, people often experience increased feelings of grief or sadness at the same time of year when the loss originally occurred. I am always amazed by this phenomena, both in my practice and in my own life. The subtle cues of weather, smells, and plants for a given time of year, along with the overt cues of time-specific activities, can unconsciously remind us of unhappier times and cause us to feel upset. This often occurs even when we aren't consciously thinking of the original trauma, loss, or upsetting event. For example, I had my first miscarriage in early October many years ago. Although after some years, I stopped consciously thinking about it on the anniversary date, on that day I would inevitably find myself, seemingly inexplicably, cranky and miserable. At the end of the day, I would finally figure out why I was so upset. Now I've come to anticipate this anniversary reaction, which has lessened its emotional impact.

Anniversary reactions are particularly strong during the holidays because there are so many cues as to the time of year, everywhere you look. There is no way you can miss all the holiday lights, Christmas carols, parties, and family gatherings. So if you had a bad time of it with the holidays last year, that alone can make you feel upset all over again this year.

I really hope your holidays are wonderful, and filled with happiness and love. But if they don't quite live up to that expectation, because of infertility or for other reasons, know that you won't be alone. Perhaps, when we stop pressuring ourselves to feel a certain way, we can be more in the moment with how we actually feel, good or bad. Often, sitting with our feelings for a while helps us to understand ourselves and our situation better and to figure out what our next steps are. Although it may be rooted in unhappiness at times, the clarity that can be gained may be the real gift of the holiday season.

Shame, infertility, and why we shouldn't feel that way anymore

2010-12-16T08:21:00.000-08:00

Well, it's been quite a week around here in my practice. I don't know if it is the stress of the holidays, the subzero temperatures, or perhaps the near lack of sunlight, but I've been hearing a lot this week about shame.

Shame is a common emotion that occurs when someone is undergoing infertility treatment. Each time I hear a person talk about feeling ashamed of their infertility, this argument presents itself--they feel ashamed that there bodies aren't functioning "normally", and thus they can't easily reproduce and fulfill their alleged biological imperative. In this way of thinking, for women, the ability to become pregnant and produce healthy babies is their most defining feature.

Thus, I hear client after client tell me how ashamed they are of their bodies because of their infertility. The real shame in all of this, from my perspective, is that I’m hearing this from wonderful, heroic people who are doing an amazing job with their infertility treatment. They are doing everything right—working hard to maximize every possible variable they can control.

Here's the other thing I've noticed--the shame doesn't stop at infertility. Even in the fertile world, women struggle with feelings of shame about their reproductive abilities. I recently met a woman who had five children, but felt horrible about herself in comparison to her sister, who had nine children. My acquaintance, although she got pregnant easily, had difficult, high-risk pregnancies and deliveries. She felt ashamed of her body—why couldn’t she do things as well as her sister, who had easy pregnancies and deliveries? Another woman I know feels terribly ashamed of her body because she used an epidural in the delivery of her child, rather than delivering naturally, like her mother did. A friend confided that she felt ashamed that she couldn’t successfully breastfeed her baby, who had severe food allergies.

In all of the above situations, everyone was doing their absolute best, and nobody could do anything else that would change the medical outcome of their situation for the better. So why did feelings of shame have to come into the picture?

I think our society has a lot to do with women’s feelings of shame about their bodies when it comes to reproduction. I've realized that the emphasis on reproduction, although it does have biological elements, is largely a societal construction--and probably, at this point, an archaic one. In an agrarian, monarchy-based society, producing heirs, and children/laborers, is important for the survival of the society.

But things are different now. Given the change in women’s roles in the workplace, not to mention our global overpopulation problems, defining women by their reproductive capacities, on a practical level, isn't such a smart idea anymore. And yet, so many women are still buying into the idea that their reproductive capacities are central to feeling “normal”, or to their self-worth.

The thing about feeling shame about things over which you have no control is that ultimately, it’s a big waste of energy and effort. The shame doesn’t magically improve the situation or provide you with more control. It just makes you feel lousy and therefore less able to function at your highest level. Shame about infertility doesn’t help you, and it doesn’t really help society either.

However, I do have a solution. The great thing about societal constructions is that they are just that—arbitrary constructions—and not actual reality. Therefore, they can, and do change over time. As individuals struggling with infertility, we can simply decide not to buy into the societal values about our bodies when it comes to reproduction. Instead, we can work on not blaming ourselves for things over which we have no control.

So please, please, do me a favor. If you find yourself starting to feel shame, take a moment and think about why. Did you just purposefully run over your grandmother’s pet weasel? Have you recently financially defrauded starving orphans? If so, go right ahead—be ashamed of yourself with my compliments. However, if you are feeling ashamed about your body, your infertility, or anything else over which you have no control—could you please try to stop? Because trust me, you don’t deserve it! And if you hear a friend start down the shame path, could you remind her to stop too? Not only will you be feeling better about yourself, but you’ll also be improving society. And in that, there is no shame at all!

Resilience is the real fertility

2010-12-09T05:02:00.000-08:00

So many times, I am asked by clients, "How will I get through and survive (insert tragedy/setback/loss here)? My answer to them, although perhaps not comforting, is always the same--that you will get through and survive the bad things that happen to you because. well, you really don't have any other choice.

Although that sounds a bit grim, I am constantly amazed by what human beings are capable of doing when they don't have the choice to do otherwise. It seems that if we have the option to escape something painful or difficult, we are usually sorely tempted to take it, even if it may not be the best thing for us in the long run. But it is when we don't have any choice in the matter, that is where the real bravery, strength and creativity become apparent. This is how I define resilience--the ability to keep functioning despite losses and challenges. I feel hopeful that our resilience as a species will be the thing that ultimately keeps the human race from destroying itself. For example, when we actually have no other option, we might finally be motivated to do something about global warming or whatever else threatens our survival.

In my work with clients struggling with infertility, I've seen that despite feeling otherwise, most people are more resilient than they may believe. When confronted with setbacks, disappointments, or losses, most people initially feel that they can’t function successfully. But as the situation evolves, they see that they are able to confront issues they never thought they could, or to give up habits that that never imagined they could. Witnessing these transformations is one of the great things about my work.

It is my belief that when it comes to creating your family, resilience is even more important than physical fertility. You can treat or work around infertility --but without resilience, you often can't make anything happen. Functioning ovaries, happy sperm, and a willing uterus are all nice to have, and make the process easier. But the ability to persevere and keep trying even when the situation is difficult is the one key ingredient necessary for success. When I think about my own situation this way, it makes me feel better. I can take comfort in the fact that although I had significant physical challenges, my resilience was intact, and helped me to take the numerous steps on the long and rocky road to having my own family.

One thing that makes people doubt their own resilience is that the process of being resilient usually isn't pretty. There are a lot of tears and bad feelings involved, along with struggles, mistakes, interpersonal conflicts, and the like. Like so much in life, it's a messy, non-linear road, and you may only realize where you have ended up once you are already there.

If during the course of your infertility journey, you come to a point where feel overwhelmed and like you can't go on, than then you should take comfort in the fact that these feelings are extremely common in this situation. It may sound like an odd thing to say, but if you still have treatment options, then even though the options may be difficult, you are still in a privileged situation. Even more difficult than going forward is the realization that you've come to the end of the road and that you have no more options with which to struggle. So if there is still a battle to fight, take heart. And remember that you are probably more resilient than you believe--and that your resilience will help you do what is necessary to create your own family.

Managing your infertility treatment--understanding your relationship with your nurse

2010-12-02T09:03:00.000-08:00

We often think of our reproductive endocrinologist as our primary treatment provider for infertility treatment. In fact we usually have much more frequent contact, and thus a more involved relationship, with the nurses responsible for the day-to-day monitoring of our care. I have always been impressed with how much responsibility and decision-making power that nurses working at infertility clinics often have. They can decide which of our questions and aspects of our clinical condition are brought to the RE's attention, and they often manage routine aspects of infertility treatment themselves. Thus, it pays to have a good relationship with your nurse--in which he or she is working with you to make sure you are getting the best medical supervision possible.

With a personal infertility career spanning the better part of a decade and a half-dozen clinics, and in hearing the stories of my clients, I have found the vast majority of nurses to be professional, competent, and kind. Many infertility nurses are truly exceptional--medically savvy, organized, and interpersonally sensitive--all traits that I believe can enhance your chances of treatment success. Occasionally, however, I have encountered some less than stellar nursing staff, and in these situations, I have witnessed the potential for negative outcomes.

To understand your relationship with your nurse, I think it is necessary to think a bit about the emotional situation involved in your nurse's job. First, she (or he, but I'm using she here because I've never actually come across a male infertility nurse, which in itself is interesting...) usually has a lot of patients to manage, all at different stages of treatment and with widely varying medical situations. She has to be on top of all the different steps each patient needs to take (imagine managing your own treatment plus 50-60 others at the same time!), as well as to be the liaison between the patient and the doctors. I think it's safe to say it's probably a fairly high stress job. In addition, the nurses, even more than the doctors, are privy to the emotional responses of patients to treatment failures and setbacks. Naturally, your nurse will have her own corresponding emotional reactions to patients' feelings (please see my blog entry on countertransference for a more thorough explanation of this phenomena). She must herself find a way to manage these emotional reactions--ideally remaining emotionally involved enough to be empathic, but with enough psychological boundaries that she does not become overwhelmed by her own feelings, so she is still able to be helpful. As you can imagine, managing these emotions isn't an easy task, and she is at constant risk of developing compassion fatigue, in which she becomes "burnt out", and may want to emotionally distance herself from her work. Add in to all this that infertility nurses are often of child-bearing age themselves, and there is a whole other set of feelings for them to manage. Perhaps they might worry that they too will struggle with infertility. Alternately, if they able to build their families easily, they may feel guilt that many of the couples with whom they work struggle and suffer so much in this area.

Warning signs

As you can see, being an infertility nurse involves juggling a great deal of emotions along with the ever-changing and fast-paced nature of the work. Despite the difficulty involved, I think that most nurses do a good job of remaining emotionally involved but still maintaining good boundaries. However, when things start going awry with a nurse, in my experience it is usually because she is struggling with this task. For example, I have sometimes observed that nurses can take an "us vs. them" attitude towards patients. This can come across as the nurse appearing impatient and irritated with patients when they have valid questions or concerns. It may seem that the nurse in question has a condescending attitude towards patients, in which she treats them as if they know nothing about the medicine involved, and that only she or the doctor are the experts. Because she is not listening to patients fully, or valuing the importance of what they say, she is at risk for missing important clinical information crucial to creating treatment success. And because she has reduced the level of patient trust and goodwill, she may not be getting this information in the first place.

At the crux of this "us vs. them" attitude, in my opinion, is that the nurse feels a strong need to disidentify with the patients with whom she works. In order to not feel overwhelmed by her own feelings regarding their situation, she must feel that they are entirely different from her, and is thus unable to emotionally understand their situation. In my field, we call this an "empathic break".

Although this situation is not common, it does occur, and it can really wreak havoc on an infertility treatment. In my own treatment, I once (and only once) had to fire a nurse off my case because repeatedly, she would not listen to me and refused to take my concerns seriously (which turned out, after speaking to other staff, to be entirely justified.) As I was rather far along on my own journey, I knew that this was not going to work for me--and that there were many other fantastic nurses with whom I could work-so I took the step of speaking to the clinic manager and requesting that we no longer work together. But I couldn't help but think that if I were new to the situation, and didn't know that things could be different, she could have really messed things up for me.

So my advice is, if you continually and repeatedly get the feeling that your nurse is not listening to you, is irritated with your worries, and is repeatedly unempathic to your feelings, you may need to consider talking to her or someone else about this situation. Of course, everyone, even nurses, can have a bad day, or even a bad week or month--but if it is never good, and talking about it doesn't improve the situation, you may need to consider making a switch.

Fortunately, as I mentioned earlier, this type of situation is not the norm. Most likely, you are already working with a good nurse. How can you make your relationship with her the best if can be? In my opinion, the most important facet of your relationship with your nurse is building good will between the two of you. If she can feel that you are a nice person, and someone with whom she can identify, she will be more positively emotionally involved in your case. She will want to help you succeed even more. She will be more likely to take your case to the doctor and think proactively about problems or issues which could occur. You will feel like she likes you, and you will be more open and forthcoming with her, which means she will have all of the necessary information to help the doctor make the best treatment plan. In my opinion, having a good treatment relationship with your nurse can be one of the major ingredients to treatment success.

Acknowledge her situation

As in any working relationship, if you can understand the needs and the situation of the other person, you will be better able to build good will and thus work collaboratively. For instance, if you can show your nurse that you are aware of how busy she is, and of the intellectual and emotional challenges of her job, she will be much more receptive to your needs. If most of the time, you only sound the alarm bell when it's necessary, you will be forgiven the occasional freak out or minor neurotic episode (all of which are inevitable in infertility treatment). Perhaps more importantly, though, you will build good will.

Be visible--but in a good way!

As a patient, one has to walk a fine line between being patient and trusting that the nurse or doctor will address your issues on their own, and being assertive and calling their attention to your concerns. If you simply trust that your nurse will take care of everything, you may be at risk for things being overlooked. If you are too aggressive or always making a big deal out everything, you are at risk for being seen as a "problem" patient. The key strategy here is to educate yourself about your own treatment plan and situation, and to bring up concerns as you have them--but in a polite and respectful way. Don't yell, and give the staff time to call you back or respond to your e-mail. If they don't respond, then you may have to be persistent--but again, in a calm and respectful manner. Remember, there's always time to yell at somebody about something later--but you can't take it back once it's done!

Apologize if necessary

Remember when I said that everyone is entitled to bad day or week every once in a while? This also applies to infertility patients. Given all of the hormones and emotional high stakes involved, it's not unexpected that you might not be at the top of your game, or at your most charming, during some contacts with your nurse. If you feel there are some situations you could have handled better, it might help to talk to her about it. In most cases, you will be greeted with an understanding and appreciative reception. Again, this will help rebuild the good will between the two of you--an ingredient helpful for treatment success.

Show your appreciation

Just as in our own lives, nurses appreciate being thanked for their hard work and efforts, especially if she has gone out of her way for you. If you feel she has done something truly exceptional, in addition to letting her know personally with a thank you card, kind e-mail, or occasional baked good, you could also let her office manager or supervising doctor know how much you appreciate her work and skills. These small gestures can help your nurse recognize the positive impact she is having on people's lives, and that can really get her through the difficult aspects of her day.

In sum, creating good will between you and your infertility nurse may help your treatment be successful, but even if it doesn't, it will at least make your treatment more pleasant. It may also provide you with another person who can understand your situation and offer emotional support.

A infertility Thankgiving story....what I know now and what I wish I knew then

2010-11-20T15:49:00.000-08:00

Each week, as I search for a topic for this blog, I find myself reliving in my mind the various stages of my own long infertility career. That, plus the onset of the holiday season, has reminded me of my very first infertile Thanksgiving. A decade later, as I look back at that day, I now realize it was a microcosm of sorts for all of the issues that I would face in the coming years. And with the distance of time, I can now see facets of the situation that had until now gone unrecognized.

The day before we traveled home for that Thanksgiving, I had just learned that my first treatment cycle, a Clomid/IUI cycle, had failed. Like most newcomers into fertility treatment, I was convinced I just needed a "little help", and that this would do the trick. I was shocked and devastated to find out it didn't work. That, plus the sudden and unwelcome arrival of a few extra pounds, (thanks to Clomid and progesterone) left me feeling rather depressed. My husband was not in touch with his own feelings regarding our infertility diagnosis and the failed cycle and seemed surprised that I was so upset by it--so we were definitely not on the same wavelength.

My parents, with whom we were staying, were aware of our infertility problems, but as they had never experienced anything similar, they didn't yet really understand what we were going through (although now, with so many years of experience, they are experts!). I'm not sure what my brother or sister-in-law knew at the time--I know they were aware of the fact that we had been trying to have a baby for over a year, but I don't recall now whether or not they yet knew we were in treatment.

In any event, we were all gathered around the Thanksgiving table when my brother announced, "We're pregnant!" My father, ever the kidder, wanted to know how my brother, along with my sister-in-law, could possibly be pregnant. My mother seemed unusually reserved. My sister-in-law told her own mother that she could stop nagging her now about how she needed to start a family because she wasn't getting any younger (by the way, my sister-in-law and I were both the same age--30--at the time). A mild argument ensued between the two of them as to whether or not this sort of nagging was appropriate. My husband sat next to me in shocked silence.

As I realized the import of what my brother had said, I was flooded with emotion. I felt completely blindsided; I felt an uncomfortable level of envy; I felt like I wanted to cry; I felt like I wanted to scream. Instead, I tried to keep a smile on my face and offered my congratulations, asking about her due date, morning sickness, etc. And then I worked hard to keep from crying. Needless to say, it was a very long evening.

After we left my brother's house, the tears began to fall. My parents, particularly my mother, was extremely sympathetic to my feelings. In retrospect, I was lucky that I didn't have to hear that I should just be happy for my brother, which, in the midst of everything, I was.

Thanks to my brother's announcement, my husband was now starting to get in touch with his own feelings of anger, sadness, and loss about our situation. But because I was so overwhelmed with my own feelings, I don't think I was much help to him with them. That Thanksgiving, we returned home feeling dejected, discouraged, and left behind.

This story seems to have so many of the classic elements of the infertility experience, with its surprise pregnancy announcement, sibling rivalry issues, and implicit messages that it might be all my fault because I "waited too long". In addition, my husband and I also fell into the typical relational pattern of couples experiencing infertility--we were processing emotions with different, almost incompatible different coping strategies, and at completely different times. However, in reexamining the situation, I now can see other equally important elements that at the time I missed.

Infertility has a subtle ripple effect

Of course, when my brother made his pregnancy announcement, my focus was mainly on myself, although I did notice that my mother seemed very quiet. When I recently asked her about this, she told me that when my brother said he and his wife were going to have a baby, she felt terribly conflicted. On the one hand, she was happy for him, but she knew that this news would cause me a great deal of pain. She felt that she had to keep me as her main focus at that moment, because I was the one that was hurting. Now I realize that my infertility took something from my mother too--the freedom to experience and express her happiness about the arrival of her first grandchild.

That realization made me think about my brother and sister-in-law. I imagine they were very excited to make their announcement and probably expected more of an excited reaction from my parents. I'm sure they felt hurt and confused as to why we weren't all jumping up and down and popping open the champagne. So again, my infertility took something away from them too--their hope for an enthusiastic welcome for the newest member of the family.

Of course, it all turned out alright. I honestly can't imagine life without my nephew, who is a wonderful boy, and my family is even closer than it was a decade ago. But still, I now realize my medical problems had a farther-reaching effect than I originally noticed.

The pain (mostly) goes away

Another thing that strikes me as I review this situation is how much less it hurts me now. Although I am still in touch with the feelings of sadness, envy, and melancholy of a decade ago, they are much less intense now. This is something I think it is very important to keep in mind, and something I tell all my clients--over time, you can work through your painful feelings and they will become much less intense. Even if you are feeling pretty lousy now, you can be confident that as long as you are processing your emotions, you won't be feeling that way forever.

A bit of perspective...

As I gain a little bit of distance in time from my active infertility treatment, I realize now that although it was fairly awful, it is probably not going to be the worst thing that will ever happen to me. I say this knowing that in terms of the infertility world, my situation would be classified as a "worst case scenario". In fact, this is one of the things I am thankful for this year--that so far I have survived it and lived to tell the tale. As time passes, I have seen my friends and family face their own difficult struggles, and I know that although the content of my struggle may be different than others, the process of overcoming difficulties in our lives is the same for us all.

I hope that you will have a very happy Thanksgiving holiday no matter where you may be in your journey of infertility. I am also very thankful that you are reading my blog, and would love to hear your comments, questions, and thoughts!

Upsetting things people say, and what to say back: self-protection during infertility treatment

2010-11-16T19:45:00.000-08:00

If there is one thing that I have learned from my own infertility, it is that people can say some rather insensitive and mindless things! Enduring countless questions about when you are going to start a family, admonishments that you certainly aren't getting any younger, and other helpful "advice" can wear on a person, especially a person who is already experiencing a lot of stress and disappointment. The holidays, with their many family and social engagements, especially seem to be a hotbed of activity in this regard.

It's hard to know how to respond to these types of comments. I myself still struggle with this issue, and many of my clients describe similar dilemmas. In this blog, I will outline some creative strategies of responding to these situations that may be useful.

Striking a chord

I think one of the hardest aspects of responding to upsetting comments is that they often stir up our own feelings of inadequacy or self-blame about our infertility. As I have discussed in a prior post, it is quite common for individuals experiencing infertility to worry that somehow their medical problems are caused by their actions, beliefs, or feelings, despite all evidence to the contrary. Thus, hearing, "You just need to relax" for the zillionth time can reinforce our feelings that we are somehow doing something wrong, and that is the root of the problem. Our emotional reaction doesn't take into account that rather than a lack of relaxation, there are medical issues at play--and the speaker likely does not have any expertise in this area. In addition, if infertility has already taken a toll on self-esteem, hearing about how so-and-so became impregnated merely by her husband looking at her can heighten feelings of inadequacy.

When you are experiencing negative feelings about yourself, it can be hard to formulate a response to the comment or question right in the moment. This is why I believe it is important to try to anticipate problematic comments or questions in advance. I'm not suggesting getting paranoid about it, but it can be helpful to consider what might be said or asked, and by whom. As you start thinking in this way, you will find that certain situations call for such comments, and that certain individuals can be counted on to say something insensitive or unfortunate. Planning in advance can help you to develop a plan you can implement if and when verbal misfortune occurs.

They started it!

When responding to insensitive or inappropriate comments or questions, it is important to consider that although society teaches us to answer questions when asked, and to try to be polite no matter what, in reality we have much more freedom in terms of our responses. In my way of thinking, if somebody else has already crossed a social line, then all bets are off! We often fear breaking a social rule because we worry the consequences will be severe. After you try it in one of these situations, however, you will realize that in actuality we have much more flexibility than we may believe.

Let's say someone has just said something inappropriate or upsetting to you regarding infertility or family building. How do you respond? I have a few approaches you may not have previously considered that might work for you depending on your needs at the moment.

Stonewall.

Sometimes saying nothing at all says the most. We are trained otherwise, but it is true that just because someone asks you a question doesn't mean you need to answer it. So many times, the questions that people struggling with infertility must endure are very intrusive. For instance, you probably don't go around asking fertile people with whom you are merely acquainted what sexual position they used to conceive their children. So a silent stare, and a change of subject, might be just the trick in these situations to set your boundaries in place.

Educate.

Many times, instead of answering questions or responding to comments, I have found myself giving a little manners lesson to my unfortunate conversational partner. I don't know whether they found this to be a helpful lesson, but I do know it certainly made me feel better. I was especially inclined to do this when someone pressured me about not having children, and not getting any younger. I would tell them, "You know, let me give you a piece of advice. You really shouldn't be going around making these statements or asking people these questions. You never know if someone is having a problem having children or not, and if they are, the things you are saying can be very painful. I'm sure you wouldn't want to cause anyone to feel upset, so this is why I bring this up." This usually shut down the conversation right away, although not surprisingly, I never got the sort of thanks I felt I deserved for imparting this sage wisdom.

Be outrageous

Sometimes in these situations it is most effective to think outside the conversational box. The best example of that I can think of is not infertility related, but does illustrate the point. When I was growing up, my mother provided foster care and adoptive homes for orphaned cats. Sometimes, quite a few of them were with us. Of course, they had to eat, and my mother, being thrifty, wanted to buy the cat food when it was on sale. She would get embarrassed though, buying all the cat food because people would always ask her questions about how many cats she had, why she had them, and wasn't she crazy for having all of those cats? Finally, she got so tired of this that she sent my father to buy the cat food instead. He loaded his grocery cart full of cat food, and as usual, he was approached by a woman who wanted to know how many cats he had. With a straight face, he looked at her and said, "Ma'am, we don't have any cats." He left it at that, and rolled off his cart as she struggled to contemplate what other possible uses there could be for all of that cat food.

I am sure you can come up with similar zingers for your particular situation, especially with a little advance planning. Not only will you be able to protect yourself and effectively end the line of conversation or questions, but you also may enjoy doing so.

Get the heck out of there

Sometimes, none of the above strategies are going to work. You might already be so overwhelmed with emotion that you can't continue the conversation any more. In these cases, if it feels too hard to continue, then simply excuse yourself. Try to do something that will comfort you and help you feel better, whether it's a good cry in the bathroom or hanging up the phone and yelling at the wall. You can always deal with the consequences of exiting the situation later, and hopefully the person will understand. If they don't, then it doesn't reflect well on them, does it? Dealing with the difficulties of your own situation is probably hard enough--you don't need to worry about saving the feelings of everybody else too.

Couples issues in infertility treatment: some thoughts

2010-11-09T19:12:00.000-08:00

Infertility treatment is not easy on a relationship. The logistical challenges and the emotional ups and downs involved are enough to challenge even the happiest couple. Although some couples may be able to navigate the bumpy terrain of infertility treatment without conflict, many others find it to be a tumultuous time in their relationship.

It seems that being in infertility treatment (or any other highly stressful situation for that matter)can aggravate any preexisting areas of conflict a couple might have. But more than that, I have noticed that different coping styles on the part of the members of the couples also produces a great deal of conflict.

To be honest, when people talk about gender differences in regards to expressing emotions, i.e., men are from Mars and women are from Venus, I usually get irritated. It bothers me to think of human beings as so stereotypically defined; are we merely just the product of biology and/or societal conditioning? Can't we choose how we will think and act? That's why I also find what I am about to write irritating--yet nonetheless I have found the following distinction to be useful:

Usually in each couple there is one individual who is more consciously in touch with their feelings, and who thus is more explicitly anxious and upset by the experience of infertility. And there is one individual who tends not to be as conscious of their emotions, not express them as much, and may in fact be in some level of denial about the severity of their situation. More often than not, in a heterosexual couple, the woman is the emotionally aware/anxious one, and the man is the one in the stoic/denial position. Of course this description doesn't fit everyone, but it is accurate enough of the time that despite my prejudices, I cannot deny its validity.

The good news

Although the above pattern has some problematic aspects, which I will discuss below, it can be a very adaptive pattern much of the time. The script I commonly see goes like this: the woman realizes there is a problem, and gets upset. The man feels that she is overreacting and that everything is going to be fine, if only they were more patient. Undaunted, the woman nonetheless springs into action, making appointments, beginning treatments, etc. If the man had his way, nothing might be done, and as infertility treatment is time-sensitive, opportunities might be missed. But by not panicking, and by continually pulling his partner back from the edge of the emotional cliff, he provides a stabilizing force for the couple. On balance, this "division of labor", if you will, allows the couple to move forward.

The not-so-good news

In this system, problems arise most commonly when a disappointment or setback occurs. The woman reacts immediately, becoming distressed and visibly upset. The man, although he may also be upset, tries to ignore these feelings, adopting a more stoic attitude. While the woman wants to discuss recent events and her feelings (sometimes to the exclusion of all else), the man eventually gets frustrated and does not wish to discuss the situation anymore. At this point, conflict arises, as the woman then feels her man is not emotionally "there" for her, and for his part the man feels that she is dwelling too much on her feelings. Further, the man may also feel frustrated that despite all of his efforts, he is unable to do anything to help the woman feel better about the situation--it is out of his control. This may make him feel worse about himself, and in combination with the stress of pushing down his own feelings of loss and frustration, he can then get a bit "crusty around the edges" (a clinical term :)). Eventually the tension erupts, and arguments ensue.

I have also observed a "delayed reaction" phenomenon with men; once the woman starts working through her feelings of loss or frustration and is doing a bit better, the man starts to become visibly upset. Perhaps as she is not as vulnerable, he finally feels like it is safe to process his own feelings. This can also cause conflict, because the woman feels that she is being pulled back into being upset about the situation again when she was just emerging from it. Also, if she felt unsupported in her feelings while she was going through them, she may be less than sympathetic now that he is distressed. Again, this causes a lot of tension in the relationship, which can produce conflict.

Coming back together

I have worked with many couples with the above types of conflict. What has been most helpful to them is to be able to understand each other's different coping styles. Realizing that their partner is not being willfully insensitive on the one hand, or overly emotional on the other, allows them to regain common ground and to feel that they are part of the same team. By acknowledging the emotional validity--and necessity--of both perspectives on their infertility experiences, most couples are able to reconnect and move forward together in their journey of building their family.

A postscript

This evening I came across another excellent article on the different emotional perspectives men and women can have during infertility treatment. It just came out today (I super-swear, I wrote my blog entry yesterday, before the article came out!) from the AFA. It covers a lot of the same ground, but makes some really interesting points. Here is the link:

Differing Perspectives article from AFA

Happy reading!

When you are "stuck"--impasses in infertility treatment

2010-11-03T21:38:00.000-07:00

Infertility treatment is often a long and complicated process, sometimes involving difficult choices and courses of action. Naturally, individuals in infertility treatment may need to stop and take time to consider their choices. In addition, sometimes a complete break from treatment, to recover both emotionally and physically from its demands, is necessary in order to continue in the long run.

However, sometimes what starts out as a break or a time of contemplation can turn into in an impasse, in which the individual or couple is unable to move forward. Unfortunately, such impasses are common. The noted psychologist Alice Domar, Ph.D., who specializes in working with infertility issues, recently published a study that examined the reasons people drop out of infertility treatment. She predicted that financial or insurance reasons would be the primary reason for dropping out of treatment. Instead,she found that emotional stress was the most common reason, with 50-65% of couples citing it as their main reason for ending treatment. I suspect that many of the couples who dropped out of treatment despite having the financial resources to continue were at an impasse in their treatment.

What makes an impasse different from a break? In my mind, there are a few defining characteristics. One is the duration of time involved. For example, if the planned break of a couple of months now extends to the better part of a year without other extenuating circumstances changing, it is likely that an impasse has occurred. Also, if the topic of infertility treatment is avoided or rarely discussed, this may be another sign that you are at an impasse. Conversely, if infertility issues are frequently discussed, but in an a ruminative fashion, with the same content and the same outcome, this could be another indication that there is an impasse.

Experiencing an impasse can cause delays in infertility treatment. Of course, delays can be very problematic from a biological perspective, as a woman's ovarian reserve and egg quality tends to decline as she ages, sometimes quite rapidly. But biology aside, delay can also be problematic from a developmental perspective. Having children can be seen as a developmental milestone which produces increased psychological growth. Also, people can feel left behind watching their peers create create families and have new experiences, when they have so far been unable to achieve this goal. Thus, delays caused by an impasse can have damaging and far-reaching effects.

In this post, I will discuss a few of the common causes of an impasse, and offer some suggestions for addressing this problem.

Denial

In my practice, I have seen impasses occur when someone wants to deny a painful truth about their infertility. As an example, I once worked with a married woman in her mid-forties who desperately wanted to have a child. Despite her age, history of infertility, and extremely elevated FSH level, she refused to consider the possibility that she could not use her own eggs to start her family. She became enraged when RE after RE suggested that she consider using donor eggs or adoption. Instead, she chose to try some risky alternative treatments, and was very disappointed when they did not produce a pregnancy. When I suggested that she needed to mourn the loss of having a genetic connection to a child, she became angry with me as well. Although this example is a bit extreme, it demonstrates how denial can keep us stuck and unable to move forward with a treatment plan that has the best chance of success.

Fear of failure and the defense of withdrawal

Another very common cause of an impasse in infertility treatment is the fear of failure. Feeling that you would be unable to cope with another failure or loss can sometimes cause an emotional paralysis, in which you know you want to continue in treatment but nonetheless are unable to move forward. You might withdraw from infertility treatment, and even from discussing the topic of infertility. I experienced this myself when I reentered infertility treatment after the adoption of my oldest child. Although I knew I wanted to try again, it took me over a year to make an initial appointment with a new RE. Many times during that year, I started to make the appointment, but was flooded with memories of all of my previous failures, and was unable to complete the phone call. When I finally did make the appointment, I was surprised at how relieved and peaceful I felt--a sign that the impasse was gone.

Unresolved couples issues

Sometimes, when a couple is unable to move forward with a decision or with the next step of their treatment plan, it can be a sign that there are other issues involved. If the couple is feeling disconnected from each other, for example, they may be unable to feel safe discussing emotionally charged issues. Or if one member of the couple is having doubts about continuing the relationship, they may start dragging their heels in terms of making decisions or beginning a treatment cycle. Alternately, there may be differences in terms of decision-making styles or core values that might cause an impasse in treatment. Usually, once the issue is resolved, the couple is able to move forward in their treatment.

Diagnosing and dealing with an impasse

How can you tell if you are experiencing an impasse? My first suggestion is to evaluate your treatment path, choices, and current timeline using this perspective. If there are delays that are not caused by other identifiable factors, then you might indeed be stuck.

If you do feel you are experiencing an impasse, it is then important to closely examine your feelings about your current situation. Is there something going on that is difficult to accept? Are you afraid of moving forward because you won't be able to handle it if treatment fails? Can you think of any couples issues that might be affecting your relationship?

As a final suggestion, if you are stuck at an impasse, you may want to consider discussing this with a third party, such as a good friend or a therapist. By this point, if you could have resolved things on your own, you probably already would have. Sometimes getting another perspective can really help you realize how you are stuck, and what you can do to start moving forward again.

This is your brain on fertility drugs: psychological side effects of medication

2010-10-27T16:28:00.000-07:00

Usually, at the RE's office, new patients are told that fertility medications may make them "a little moody". This is not exactly true--ask any IF veteran, and she will tell you that they have the potential to make you VERY moody. At no time was this more clear to me than during my two month stint on Lupron Depot to treat my endometriosis. After throwing my body into sudden menopause, complete with hot flashes and night sweats, I also realized I now felt extremely upset all the time. If something wonderful happened, I still felt upset. If something upsetting happened, I felt inconsolable. I was in a constant state of wanting to yell and/or sob and/or punch someone in the face. Not only is that bad for business in my line of work, it was also extremely unpleasant. Clearly, I needed to develop new coping strategies to avoid jail time--and fast!

William James to the rescue!

When I first studied psychology in my undergraduate days, I learned about William James and his theory of emotion. One of the founders of the field of psychology, James believed that emotions resulted from the experience of a physical stimulus--e.g., you see a dangerous situation, begin running, and then become afraid--rather than the other way around--you see a dangerous situation, become afraid, and then start running. To be honest, this theory never made a great deal of sense to me. I was convinced that my body responded to my thoughts and emotions, and not vice versa. However, that all changed when I started becoming a habitual user of fertility drugs.

As I described above, while taking fertility medications, I had many physiologically-based experiences that caused my emotions to careen out of control. And unfortunately, I know I'm not alone. In my practice I've heard many instances of normally calm and mild-mannered women, once on the "sauce", suddenly finding themselves screaming and harming their normally beloved crystal. Yes, being infertility treatment is stressful--but many of the reactions I've seen are so far away from the person's normal coping strategy that it's safe to assume medication was a factor.

These experiences have made me question my assumption that emotions are always a direct result of our thoughts. Now, I believe that James was really on to something--sometimes are feelings are based on bodily experiences and sensations, and not the other way around. James himself suffered from a great deal of physical illness during his life, so perhaps he experienced this first hand.

You may be thinking to yourself (especially if you happen to be taking fertility medications right now), "Okay, Dr. Smartypants, who cares? Why are you telling me this? How is exactly is William James going to help me now?" The important point is this--infertility medications mess with your body's ability to react appropriately to the stimuli around you. So if your body feels physiologically upset--adrenalin and cortisol levels elevated--your brain will look at your current circumstances to try to find a reason. If it can't find a really obvious one, it is just going to assume it's one of the things going on in front of you right now. And if you start reacting to relatively innocuous stimuli as if they are the source of your body's upset sensations, well, that's when the trouble starts. But even worse, if you get into a truly upsetting situation, your body will push the panic button and trigger the flight or fight response. During that physiological experience, it's very hard to stay calm and keep a clear head, which many of our modern-day crises require us to do.

In my Lupron Depot days, I experienced this constantly. My natural reaction was to respond to the events going on before me, as if they were the thing that was causing all my inner turmoil. But after a few weeks, I realized that no matter how I reacted or how I changed things in my life, I still felt just as upset as before. Because of my hormonal changes, I was now in an constant state of flight or fight arousal. The only way I could survive would be to use my brain to overrule my emotions and my body's natural tendency to respond. Otherwise, I was going to be in for countless pointless arguments with store clerks and crying jags at the mall--not to mention alienating my husband, family and friends.

Rule No 1--Don't react!

As a psychologist, I am very interested in feelings, especially initial reactions. I normally advise people to pay close attention to those emotions and try to be true to them if they can. However, when you are taking infertility medications, I recommend the opposite strategy. My first rule of coping with the emotional side effects of being on infertility drugs is this: Don't react! The medications have decreased your ability to appropriately respond to your environment. So you have to try very hard not to respond to any seemingly upsetting event right away. Take a breath, and before you say or do anything, cognitively evaluate the situation. Is it really as big of a deal as it feels like right at this moment? Will getting outwardly upset help this situation in any way at all? If the answers to those questions are yes and yes, then you can take the brakes off and respond. But I think you will be surprised at how many times the answers to those questions will be no's. By putting your thoughts back in charge, you can select a more productive course of action.

Rule No. 2--Enlist the support of others

Another important coping strategy is to get a significant other, such as a spouse or partner, family member, or friend to help you evaluate your emotional responses to current life situation. This should be someone who understands your predicament, and agrees--in advance--to be available to you to process your feelings. When you are upset, they can remind you to calm down and go over the details of what just happened to help you figure out the best reaction. Husbands can be great for this, but sometimes men have difficulty truly understanding how hormones can have such a large effect on emotions. Because they don't typically experience the hormone fluctuations that women do even in a normal menstrual cycle, they haven't lived this "from the inside". So it may be necessary to enlist the backup support of a friend or family member just in case they have a hard time understanding the gravity of the situation.

Rule No. 3--Avoid stressful situations

If you are in a treatment cycle at the moment, chances are you are probably doing this anyway, but I'll add a quick reminder that now is not the time to voluntarily take on anything stressful. So perhaps you might want to postpone that incredibly complicated house renovation, or having the queen over for dinner. In infertility treatment, stress is plentiful, so you can be sure there will be enough stress to keep you occupied!

A final note to all the newbies out there....

If you've just begun infertility treatment, chances are you have taken or will be taking Clomid soon. In my experience, this drug is one of the worst in terms of causing emotional side effects. I frequently refer to it as "suicidal ideation in pill form", and I'm only joking a little. If you are taking Clomid and suddenly find yourself feeling very depressed and upset, it may be a result of the medication. (Of course, if it doesn't resolve relatively quickly after your cycle is over, you should definitely get those symptoms evaluated by a mental health professional.) I hope that Clomid will be the key to your success, but if it isn't, take heart--the FSH drugs don't seem to cause such severe reactions.

The end of the line? The decision to end infertility treatment

2010-10-20T09:51:00.000-07:00

A reader asked me to address the issue of how you can tell if you should stop infertility treatment. This is a very important question, and one that is perhaps impossible to answer. However, I am going to try my best to share my thoughts on this subject, for whatever they are worth.

Sometimes the decision to end treatment is basically made for you. A biological event occurs, like being diagnosed with a serious illness, that makes continuing in treatment unwise. In other cases, diagnostic information comes to light that makes the possibility of success so unlikely that continuing in treatment is pointless. Also, financial or practical considerations may arise that make it simply impossible to continue in treatment. However, in most cases, the situation is not so clear cut, and it becomes a judgment call as to whether or not you should continue.

The way I think about the decision to terminate infertility treatment is centered on one of my fundamental beliefs--that we should try whenever possible to anticipate what our future selves will think about our decisions, in order to minimize future regrets. Having children (or not having them) is a very important, life changing decision. Thus, I feel it is extremely necessary to really think about how you will feel about your choices ten, twenty, or thirty years in the future. As an example of what can happen when you do not take your future self into consideration, I would like to tell the story of a lovely woman that I know from my hair salon. She is now in her late 80's and is suffering from some cognitive dementia, so although she has met me several times, she does not explicitly remember talking to me before. Despite this, she always sits down with me and tells me her story, each time with more nuance and detail. In a nutshell, she and her husband had a baby when she was in her early twenties, but sadly, he was stillborn. She wanted to try to have another baby, but her husband was insistent that they should not. He felt if God wanted them to have a baby, he would have let their first baby live. As time went on, she still wanted to have a child, and suggested that they adopt. Again, her husband was adamantly against this--to him, God obviously did not want them to have a child, and besides, he was not interested in raising "someone else's children". She loved her husband and wanted to stay with him, so she put her dreams aside, and stayed with him through thick and thin. Every time she told me this story, she stated that although she is very sad about not having a child, she feels she must come to peace with it. But it seems to me if you are telling this (and only this) story sixty years later to a relative stranger at the hair salon, you may never come to peace with the decision. Although she has led a rich and full life, and has wonderful extended family that make sure all of her needs are met now (including making sure her hair looks fabulous), I am pretty sure that remaining childless was not the right choice for her. And the deep regret that she expresses is the kind of thing I think we all want to avoid.

If it's over, you'll know

So given that you want to make sure that in the future, you do not have profound regrets, how do you tell when it's time to call it quits with infertility treatment? My personal and clinical experience has taught me this: when it's time to quit you will know it. You will feel it, almost as a physical sensation--something like, "I can't do this anymore, it's bad for me." Your self-protective mechanism will kick in, and saving yourself will become the most important goal. I vividly remember the moment of my decision to quit infertility treatment. I had a break at work, and was pacing back in forth in my office when I realized that although I didn't want to stop trying IVF, I had run out of treatment options. If I kept going, it would be sort of like gambling--the odds were stacked against me. I had the profound sense that I would be really hurting myself if I continued, and to no good end. I acknowledged that I was really bad at getting pregnant--but maybe there was something else at which I was good, and it made more sense to put my energy toward that. We turned to adoption, and so far I have never regretted that decision.

But the heart wants what it wants...

However, if you feel in your heart of hearts that you would like to continue, but that maybe you shouldn't because it is expensive, time-consuming, or other practical concerns--then it is a different story. In this case, I think that if you could logistically make it happen, you should probably continue in treatment. Infertility treatment has a time-stamp on it, so you don't want to be looking back 10 or 20 years down the line, when you don't have the option anymore, and wishing you tried when you had the chance. The heart wants what it wants, and if continuing is what is in your heart, I think it is important to try to honor that. Whether or not it results in a baby, at least you will have the closure of knowing you tried everything you could to achieve your goal.

I know that this way of thinking comes at a price, usually financial. I personally hate the fact that money can be such a primary factor when it comes to decision making about creating a family. But money can usually be earned or borrowed, although admittedly not without significant sacrifice. However, having a child is such an important part of life that it may be worth taking on more financial risk or burden in order to maximize your chances.

As for the time, logistical difficulties, and other inconveniences involved with infertility treatment, I would urge you to remember that although it may be difficult in the near-term future, if you avoid these things now, you may be feeling regret later for many years.

As in so many things in life, we must balance our short-term needs with our long-term goals. It is never easy, but I think you should keep in mind that this is one of the most important decisions you will ever have to make. This will help give you the necessary perspective--and courage--to do what you need to do to protect your future happiness.

Infertility treatment, love and courage

2010-10-13T20:13:00.000-07:00

In infertility treatment, it's pretty easy to name the negative processes at play. The longing for, and not yet having, a child. The uncertainty and waiting for answers. The invasive, expensive, and time consuming medical treatments. The soul-crushing losses and disappointments. The havoc it can wreak in important relationships. The list goes on and on.

And yet, in my practice, intermingled among the pain and the losses, I can see moments of incredible heroism. Amazing acts of generosity and compassion. And profound expressions of love for an unborn or unknown child, made through hard work, risk-taking, and physical and emotional sacrifice. In order to survive all the difficulties, I feel it is important to step back and acknowledge these amazing moments and the profound impact they can have.

Chances are, your own personal struggles with infertility also contain such positive, love-filled, and heroic moments. But it may be hard at times to see them, because the pain of the situation obscures them from view. In this post, I will discuss the role of love and heroism in infertility treatment.

Love

Infertility boils the desire and love for a future child down to its essence. When a baby doesn't come the easy and fun way, it forces the hopeful parents to really think about what they are doing. Now, in order to have a child, they must give something up, starting with their privacy and intimacy in the baby-making process. As treatment progresses, the sacrifices continue, whether they are physical, logistical, financial, or emotional. And sometimes, if it becomes clear that parenting will only take place through using donor gametes or adoption, they must give up their own genetic connection to their future child.

I feel that at the end of the day, the thing that gets most people through all of these sacrifices is their love for their wished-for child. In a "normal" situation, this love would be taken for granted, as the assumption is something like, "I love my child because he or she is created by and similar to me". But when this is all stripped away, it becomes clear that most people have the capacity to love a child no matter how he or she was created or if the child is genetically similar to them or not. People in infertility treatment, because of their situation, know this first-hand. I feel there is something very powerful in this self-knowledge. Sometimes, people without fertility issues have expressed to me that they doubt they could ever go through the hardships of treatment or be able to love an adopted child. This always makes me feel sad for them, because I think what they are really saying is that they doubt their own capacity to attach to or love a child if the conditions aren't exactly perfect. Knowing for sure that you have the capacity to love and care for a child, no matter how they came to be in your family, puts you directly in touch with the best part of yourself, and the best part of human beings in general.

Courage

It has often been said that being brave is not acting heroically in the absence of fear; rather, it is being afraid and acting heroically anyway. Infertility treatment, if it doesn't work initially, often requires these moments of courage. We must keep trying when the stakes are high and the fear of disappointment is strong. Or perhaps we must muster up our courage to accept an unwanted truth or outcome, and to come up with a new plan to make our dreams of a family come true.
Many times, we must perform these courageous acts even when we are feeling hurt, scared, and angry at our situation. Although it is difficult, I frequently witness "ordinary" people rising to the occasion, and performing profound acts of heroism. Although these acts may be private in scale, they are just as courageous as many of the more public acts of heroism we see on the news.

I feel that experiencing yourself as courageous, even in the face of adversity, is very powerful. It puts you in touch with the best and strongest parts of yourself. Also, it is something you can take with you to the other difficult situations that will inevitably come up in life.

So in those tough and demoralizing moments in your infertility treatment, try to think of the ways you have been courageous and brave, and the ways your love has helped you to transcend significant difficulties. I think that you will be impressed and encouraged by what you have done--and this may help give you the strength to pursue your next step down the path towards creating your family.

Infertility and competitiveness among women--a question

2010-10-09T12:19:00.000-07:00

Here is a question for those out there in cyberspace who might be reading this blog...during your interactions with the "fertile" world, have you ever felt that women were using your infertility to somehow position themselves as "better" or "superior" to you?

I would like to hear about other people's experiences in this regard because this issue has confused me for years, both on a personal and professional level. I, as well as many of my clients, seem to have had this experience. However, because the social cues involved are usually not overt, I myself could never be sure if it was her or it was me--was I projecting my own competitive feelings onto her, instead of the other way around? An example that comes to mind occurred with a colleague with whom I briefly shared office space. This woman was familiar with my personal struggles with infertility. When she announced her pregnancy during a staff meeting, she made a particular point of telling me, in front of everyone, that I should drink that bottle of diet coke she had left in the office refrigerator--it wouldn't be a problem for me to drink all that caffeine and nutrasweet like it was for her. Now, at the time, I experienced that as rather hostile attempt at one-upmanship. But I suppose it could have been my issue with her pregnancy--who knows, maybe she really just didn't like diet coke going to waste. (As much as I love diet coke, I never could bring myself to drink that particular bottle.)

In my practice, I've heard clients recount numerous tales of belly-rubbing, insensitively-timed pregnancy announcements, and snide comments that sound, on the part of the pregnant ladies in question, suspiciously competitive to me. But again, I hear everything through the filter of the person who is describing the situation. So it is hard to know definitively.

My guess is that sometimes this type of competitiveness is occurring, because I think we all know people in our lives who, in order to maintain their own self-esteem, need to feel superior to other people. For them, I don't suppose infertility or pregnancy would be off-limits in those cases.

However, I also think that sometimes, it might indeed be projection of our own competitive feelings onto the other person, who is most likely caught up in her own life and not thinking about our problems at all.

Anyway, if you have any thoughts on this matter, I'd love to hear them! Hopefully, through sharing our experiences, we can gain greater clarity on this issue. Thanks for reading!

Ambivalence--its role in decision making in infertiity treatment

2010-10-07T04:14:00.000-07:00

Individuals in infertility treatment are often faced with difficult and life-changing decisions. Usually, there is no "right" option involved in these decisions. No one but you can decide, for instance, if you should keep going in treatment or if you should call it quits. Or if you should change RE's, or try a different clinic. Or if you feel comfortable with using an egg or sperm donor, and if so, how you feel about the disclosure of your future child's genetic origins. Or if you should start to pursue and adoption, and if so what type...the list of big decisions goes on and on. For almost all of these decisions, your choices, although they will be limited by your medical and financial circumstances, will be primarily based on your subjective preferences.

Figuring out your subjective preferences, however, may not be so easy. These situations are usually very complicated and involve emotions from many aspects of your life. Further, many of the types of decisions listed above are "workarounds". Already, they involve feelings about the loss of being unable to have a baby without treatment. So naturally, these types of decisions are going to bring up some negative feelings--even if, in the end, they are going to be the "right" option for you.

On the other hand, sometimes our negative reactions are telling us that an option would not be the right thing for us to do. It can be tricky to sort out when we are just experiencing "predictable" ambivalence, and when we should make rule out an option based on our negative feelings. In this post, I'll discuss some of the distinguishing features of the two types of negative feelings.

Ambivalence

in graduate school, a former supervisor once told me, "ambivalence is the hallmark of mental health." At the time, I gave him the same puzzled look that I now routinely get when I say this during a session with a client. But with the benefit of time and experience, I increasingly understand the wisdom of his statement. To be able to be conscious of and tolerate, at the same time, both positive and negative feelings about a person or situation (e.g., ambivalence), and still be able to function successfully, requires psychological maturity and sophistication.

When it comes to the types of decisions that come up in infertility treatment, ambivalence is practically a given. Even so, many of my clients have been concerned when they experienced negative feelings about a family building option,especially initially. They have worried that this means they shouldn't even consider the option, even if it may be the most practical or probable solution. In fact, in my work, if I hear a client express uniformly positive feelings about issues such as the ones listed above, I usually become concerned. My worry is that they aren't consciously dealing with some important feelings--and this might cause them problems in the future.

As an illustrative example, I would not expect someone to be thrilled upon deciding to use a gestational carrier, especially during their initial considerations. So feeling okay about the decision of using a gestational carrier might look something like, "I'm sad that I won't be able to myself be pregnant with my child, but I'm happy that I will be able to become a parent to a newborn". Tolerating feelings of disappointment, loss and perhaps envy along with the excitement of the pregnancy and anticipation of becoming a parent--that's the cost of doing business in this situation.

When no means no

There are times, however, when your negative feelings are telling you something important--that you are fundamentally uncomfortable with the option before you. This will look different than the types of ambivalent feelings I described above. One difference is that in ambivalence, the intensity of the negative feelings tends to lessen over time. Once you start grieving the losses these decisions involve, the benefits of the decision seem more prominent. However, if your negative feelings are telling you that this is not the right decision for you, they tend to remain present, and even increase in intensity--until you respond to them.

Another way to distinguishing factor between the two sets of negative feelings is how you feel after making the decision. I have observed this difference many times in both myself and my clients. If you have made the right decision for yourself, you will tend to feel a sense of resolve and peace mixed in with all of the anxiety the situation produces. Although you are aware of the downsides involved in your choice, you still fundamentally feel that no matter what the outcome, this decision is the best for your current situation.

On the other hand, if you continue to have consistent feelings of unease, repetitive nagging doubts, or continued intense negative emotions, you probably need to take a step back and reexamine your decision. It may be that you have decided to do something (or, as many times is the case, not to do something) that really isn't right for you. The good news is that even though you may have to change course, you can use these feelings to help guide you to a decision that does feel more in line with what works best for you in your life.

A cautionary tale of two treatments--the roles of emotion and the scientific perspective in infertility treatment

2010-09-29T21:09:00.000-07:00

Being a clinical psychologist, I am naturally drawn to thinking about emotions. They are the currency of my work; it almost always seems to me like it's a good idea to discuss them, understand them, and draw them out. And yet, when it comes to infertility treatment, both my professional and personal experience have taught me that they must be managed differently than we manage most things in our personal life. Too often, our emotional issues can blur our vision of ourselves and our treatment, and we are unable to see what is really happening at the time it is occurring.

These emotional experiences, as I've discussed at length, are difficult to manage, and are likely to color both our medical experiences and our decision making. In particular, those feelings of self-blame or doom, are often present. As discussed in a prior post, these feelings can make the success or failure of treatment seem like some sort of spiritual or karmic comment on your worth as a person or fitness to be a parent.

The science experiment mindset

In addition to being unpleasant, such feelings cloud what I think is the real truth of the matter: instead of being about you as a person, infertility treatment is all about chemical and hormonal reactions and cells in a petri dish. And what those cells and hormones decide to do is, in many ways, out of anyone's control. It's really your own personal science experiment. The doctor has a hypothesis based on past research and clinical experience, and he or she tests it out on you to see what happens. If it works, great--if it doesn't work, then there is more information to be used in the development of the next hypothesis, or treatment plan.

The best way I can think of to illustrate this point is to describe some of my own experiences in infertility treatment, to show you how I came to this point of view--and why I am so convinced of its usefulness.

Please do as I say, not as I did....

I learned the importance of taking a scientific perspective on my infertility treatment the long, hard, and painful way. My first few IVF cycles were emotionally devastating for me, fraught with feelings of failure, frustration, and disappointment. Aspects of my infertility were unexplained, and I filled in the scientific blanks with karmic explanations--perhaps I was somehow a bad person, and that was why this was happening to me. Of course I knew it wasn't logical, but in my experience logic usually never stops anyone from believing the worst about themselves, if they are already so inclined. In addition, my RE was the warm and fuzzy type, and seemed visibly upset whenever things didn't work. During one transfer, he was actually praying out loud to God that it would work this time (no pressure, right?) It didn't. I started to feel that not only was I failing my husband and myself, but I was failing him as well.

Eventually I couldn't take it anymore and I quit treatment. Screwing up all of our last remaining courage, we decided to adopt, and that process, although it had many, many bumps along the way, worked out in our favor. It was only years later, when we wanted a second child,that I began to even consider the possibility of infertility treatment again. The adoption climate had changed, and adoptions in my daughter's birth country had become extremely difficult.

I knew that if I were to reenter infertility treatment, I couldn't do things the same way. So we went to a different RE, who although he was known for his clinical excellence, was often described as cold or lacking in his "bedside manner". During our first meeting, it was clear right away that this guy didn't care one whit about me or my problems. And I had an epiphany--instead of feeling hurt by this, surprisingly I felt incredibly liberated. If my treatment didn't work, he wasn't going to be emotionally hurt by the situation. In addition, the new RE was able to systematically review my prior cycles, and explained all the variables that might have caused them not to work. Amazingly, he none of them included karma. Instead, it was all about the numbers--the clinical techniques used, the statistical success rates of the clinics involved, and the advancements in science since I had left treatment. Again, another epiphany--this was really just all a big, very expensive science experiment. The clinic would try some different protocols on me and see what happened. If they didn't work, it was just more scientific information about what might possibly work in the future. And if it didn't work at all, than it was because science hadn't yet developed the solution to my problem.

I decided that if I could hold on to that viewpoint about treatment--that it was just a science experiment--I could probably survive another go at things. And that treatment experience was much more tolerable, even though it certainly had its ups and downs. I would never say I wasn't emotionally invested in the situation, because of course I was. But I was also able to get a tiny bit of distance from things and think rationally about what was going on at the time. Medications, which may or may not be effective at their purpose. Cells in a dish, with their own agendas. Thankfully this time the a few of the cells' agendas aligned with my own, and I became pregnant with my second child.
But even without that positive outcome, I had learned something profound--by holding on to the idea that it was a big science experiment, it was possible for me to go through a treatment cycle without becoming overwhelmed by my negative feelings.

And believe me, if I can do it, you can too! It is my hope that by sharing this story, you will be able to avoid some of my mistakes, and that you and your course of treatment will benefit.

So try to remember this mantra when treatment gets stressful--in the end it's about the science. About chemical and hormonal reactions. About cells in a dish. And maybe this will give you a little bit of emotional distance, enough to see your options clearly, and to make the decisions that are right for you.

When she's pregnant and you're not: infertility, envy, and acceptance

2010-09-23T04:19:00.000-07:00

One significant psychological challenge for those encountering infertility is dealing with the constant stream of pregnancies in the lives around them. Whether it is at work, with friends or family, or just walking down the street or through the mall, pregnancy is everywhere. When I first was diagnosed with infertility, this struck me as unfair--how could everyone else move on with their life goals when I was completely stuck? Even now, I am occasionally caught off guard by my reaction to the pregnancy of others. The other day, my neighbor, who is a lovely and wonderful woman, stopped by to invite me to her son's birthday party, as well as to announce she was pregnant with her third child (a fact which I had sussed out weeks before...but more on that later). "I just had a third one in my heart. What about you?", she asked. Without thinking too much, I blurted out, "Wow, it never even occurred to me that it could just be up to my heart!"....and created yet another of my trademark awkward social moments.

Thanks to research done on those struggling with infertility, as well as my own clinical work, I know that, unfortunately, I'm not alone in these types of responses. In this post, I will explore some of the common reactions that people experiencing infertility have to the pregnancies of others, and will also suggest some coping strategies that may be useful in dealing with these feelings.

The dark side

One distressing facet of infertility is that it can bring up feelings that we'd rather not experience. Nowhere is this more true than when it comes to reactions to the pregnancies of other women. Although reactions to pregnancies will vary, depending on the people and situations involved, it is quite likely some of them will include intense negative feelings such as envy, jealousy, and anger. While understandable, this is often very difficult for people to tolerate. If a person is not used to feeling this way and is not consciously aware of their capacities for these feelings, it can be very shocking to be confronted with such negative emotions. I frequently hear clients berating themselves because despite their best efforts, they can't "just be happy" for the pregnant woman, and instead are flooded with envy and anger. I have also heard countless confessions of clients who shamefully admitted they imagined hitting, tripping, or yelling at pregnant women on the street. (As you might expect, these were just fantasies--no pregnant women were ever harmed!) And all of these clients hated that they felt this way.

Most people are very uncomfortable acknowledging their own capacities for negative emotions. And yet, they exist in us all, despite our efforts to keep them out of consciousness. I think they are probably "hardwired" into our emotional system, in order to give us the energy and the will to protect ourselves from physical harm. Dealing with them is a little trickier in modern day society, in which harmful situations often don't require a physical response, but a psychological one.

Like it or not, the natural psychological response to seeing someone else get something you desperately want, and for which you have been working very hard to achieve, involves feelings of envy and anger at the unfairness of it all. Add to the mix that the desire to have children is usually very strong and a fundamental part of life, and the stage is set for some very strong feelings and emotional reactions. Unfortunately, I don't really see a way around it. You can, and should, control your actions around these feelings--for instance, not acting on the urge to trip that nice pregnant lady--but you can't just will your feelings out of existence.

Thus, the first step to dealing with these feelings is to remember that even though they are unpleasant, they are normal. Beating yourself up for having them really isn't fair, and it's probably not going to change how you feel. Although you may have to live with these feelings, you can find ways to cope with them so that they are not too overwhelming.

The invention of "pregdar"

I'm not the kind of person who loves a surprise, particularly when it's the kind of surprise that is going to send me into an unpleasant emotional tailspin. When I was in the beginning of my infertility treatment, I was not attuned to the pregnancy plans, or slight changes in behavior or appearance, of the women around me. However, a few painful pregnancy disclosures later, I had learned to spot the telltale signs of early pregnancy. While I am not always right, overall I have a pretty good track record. My "pregdar" has been very helpful to me, because if I could anticipate a pregnancy before it is announced, I had the luxury of processing my negative feelings in advance and in private. Now, I am not suggesting you make every woman you see pee on a stick, but I do think it is helpful to be aware of the possibilities and anticipate upsetting pregnancies ahead of time.

Being honest about your feelings

Sometimes just being honest about how you feel may be useful, although it will not work, nor would it be appropriate, in every situation. If the pregnant woman in question is a good friend or relative, yet you are finding yourself having negative emotions about her pregnancy, telling her about them gives the two of you the chance to process these feelings together. Chances are, if you say it nicely, and she's an important person in your life, she is going to understand how you feel. She may be worried about your reaction anyway, and will welcome the chance to discuss it. Many times, after these negative feelings are discussed, they greatly lessen in intensity, making room for more positive feelings, including "just being happy" for the other person.

If all else fails...

Of course, there are some situations in which you just can't process your feelings with the pregnant person. And others in which processing these feelings did not produce the desired result. Further, there are some pregnant women to whom, for various reasons, you will react to more strongly. In these cases, avoidance can be a useful short-term strategy. Much has been written about this strategy already, so I won't belabor the point. But remember, you can give yourself permission to skip the baby shower or bow out of pregnancy related conversations when possible. Although it's not ideal, you are just a human being, and you have your limits, just like everyone else. Acknowledging them, at least to yourself, can give you the freedom to control when and where your negative emotions are experienced and expressed.

In sum, although negative emotional reactions to the pregnancies of others can be distressing, they are understandable and to be expected. Accepting and acknowledging these feelings allows you to be more in control of when and how you express them. As these feelings are not exclusive to infertility treatment, learning to deal with them now may be one of those little "fringe benefits" of the current situation, because in the future, when they are stirred up again, you will have a coping strategy already in place.

The negatives of positive thinking--denial, optimism, and pragmatism in infertility treatment

2010-09-16T14:15:00.000-07:00

One question I am frequently asked by clients in the process of infertility treatment is what sort of attitudes and expectations they should maintain about the outcome of their treatment. In my experience, it can be common for some infertility patients to maintain a very optimistic outlook regarding their chances for success, even in light of indications to the contrary. Frequently, people with this outlook are seemingly afraid to explicitly acknowledge the possibility of problems or failure. In this post, I am going discuss some of the pitfalls of this type of thinking as it relates to infertility treatment.

Why thinking positively may not always be the best thing to do

You may be wondering what on earth could be wrong with maintaining a positive attitude in even in the face of a challenging situation. I realize that my argument does fly in the face of much conventional wisdom, but I think that having an unqualified positive attitude may give rise to two problems. The first is that it can make it difficult to acknowledge and respond to important medical and situational information. The second is that it can make it difficult to acknowledge, process, and respond to negative emotions, such as fear, anger, despair, and hopelessness, that are an all too common part of the experience of infertility.

In our culture, there has been a great deal of recent emphasis on thinking positively, as epitomized in books such as "The Secret". The fundamental gist of these beliefs is that to get a positive outcome, you must only think positive thoughts about your situation. Thinking negative thoughts is not good as it will somehow bring negative energy, and negative outcomes, your way. You have no idea how much I wish that it was really that simple, because life would be a much, much better place. But the fact is that although you can think as positively as is possible, the power of your thoughts cannot change the physical reality of the situation. I remember in my second IVF cycle, I decided to use a lot of positive imagery and visualizations as a way of improving my ovarian response. During the early part of the cycle, when we could still travel, my husband and I serendipitously came across $300 round trip tickets to Hawaii. What better place to have a positive attitude? One day as I snorkeled among the beautiful fish through the sunbeams, I imagined the warmth of the sun healing my underachieving ovaries. Then unbelievably, I was suddenly joined by a pod of spinner dolphins, who surrounded me, leaping in the air. The pod was filled with several pairs of mother and baby dolphins--what could be a better omen than that, right? Flash forward to my first big ultrasound for that cycle, and--you guessed it--there was no dolphin magic for me. Although it was an amazing experience, it didn't change the reality that my ovaries were not up to par. If I didn't accept that information and respond to it, both practically and emotionally, I would not be able to make decisions to maximize my success given my situation.

In my opinion, not accepting the possibility of a negative outcome, or believing that positive thinking can trump physical realities, really isn't positive thinking at all. Rather, it is denial. It is much more common in infertility treatment among people who tend to use denial as their main psychological defense in other areas of their life. And I've seen it have some very negative long-term effects in people's lives. So trust me, you don't want this to be you.

Secondly, I have found that some people are afraid that if they consciously acknowledge their negative feelings about their prospects, they will somehow "cause" their treatment to fail. The idea that negative thoughts or feelings by themselves can produce some sort of negative outcome is quite common and in fact is a normal part of our childhood emotional development. If we don't get the proper responses to our negative emotions as children, this belief can sometimes persist, albeit unconsciously.

However, if we deny ourselves the opportunity to acknowledge and express negative feelings as they come up (and in infertility treatment, believe me, they are going to come up sometimes) we unwittingly create more problems. In order to avoid awareness of our negative feelings, we must use up a lot of psychological energy. This can be exhausting and draining, but may lead to a more serious problem--it can chronically raise our cortisol levels, which has been linked to several negative health outcomes and may even impair our fertility--although the jury is really still out on that one. Plus, we don't get the benefit of the information about ourselves and our situation that our negative feelings are giving us. Just as thinking positively cannot transcend our medical reality, acknowledging negative feelings and working through them in a measured way can't make our medical reality worse.

The power of practical thinking

Now I am by no means suggesting that one should adopt a doom and gloom attitude when it comes to infertility treatment. I believe that positivity has its place, and that optimism is a very useful outlook. But it must be tempered with an awareness of the problems that we currently face, as well as the negative outcomes which potentially occur. As much as I've witnessed bad things happen to people in their infertility treatment, I've also witnessed true miracles. But these miracles usually happened to people who acknowledged the problems in their situation, and adapted their treatment strategy to them--often with great daring and personal sacrifice. It has taught me that true optimism and hopefulness isn't really what you think or feel--in the end, it's what you do that counts. Pushing ahead as best and as wisely as you can, being fully aware of the emotions involved and the risk of failure--to me that's optimism and bravery at its best.

When you and your body are on the "outs": negative body feelings and infertility

2010-09-09T15:03:00.000-07:00

Infertility is, at its base, a medical condition. Whatever the cause, there is some part or parts of your body that aren't functioning as intended. Not only is this difficult from a pragmatic perspective, it is also difficult from a psychological one. Suddenly, you and your body are at odds--you want it to do something, and it can't or won't! Of course, your body is actually you--and it's probably trying as hard as it can--so this can cause a psychological dilemma. While this psychological dilemma is present in many illnesses, it can be especially intense during infertility treatment because reproduction is such a primal and important emotional issue. It's important to think about these feelings because being angry, frustrated, and disappointed with your physical self all the time is not a fun way to live.

Trust me, I know this from personal experience. My rocky relationship with my ovaries started to go sour during my early attempts at treatment, and took a very sharp downward turn during my first IVF cycle. Despite all the medication, despite all the positive imagery I conjured, and despite all my mental cajoling, it soon became clear--my ovaries were slackers. I remember one of the IVF nurses yelling at me in frustration, saying, "You are only 32. You should have five follicles up and down on each side. What is the problem with your ovaries?" As if I knew, and as if I could somehow convince them to act differently. Later, I was at a restaurant ordering dinner, when a poor unsuspecting waiter, trying to be mindful of my dietary requirements, asked me, "Are eggs a problem?" My eyes welled up with tears as I told him that yes, indeed, eggs were a HUGE problem. I don't remember much of the rest of that evening, perhaps because after the waiter fled in horror, I was served a generous amount of free martinis by the manager of the restaurant. Now, I wouldn't really recommend martinis as a long term coping strategy, but my point is that I (and to some extent the IVF treatment staff) started viewing my internal organs as a huge impediment to my happiness.

Plus, if you are female, your infertility related anti-body feelings can join force with your more general anti-body feelings. There are so many industries that exploit our negative self-images; our bodies are presented as things that need to be changed--perfumed, covered with makeup, botoxed, and made smaller.
Combine this with infertility, and its pretty easy to build up quite a bit of self-loathing.

Self-loathing is pretty bad just on it's own, but when you are going through a stressful time (like infertility treatment), it can make it harder for you to cope. In a prior blog post, I discussed the common tendency of people to blame themselves for their infertility. Body based-self loathing plus karmic self-loathing can lead to depression and other sorts of chronic unhappiness.

So, if you are finding yourself at odds with your physical self, what can you do to heal the rift?

1. Acknowledge your feelings

I think the first step is to try to figure out exactly how you feel about your body during the infertility treatment process. If you are finding yourself feeling grouchy and tense with yourself all the time and don't know why, one root cause may be your feelings about your reproductive system. Don't expect your feelings to be rational or even make sense. Just acknowledging them can provide some element of relief.

2. Try to develop empathy with your body

If you had a sick friend who couldn't get out of bed, you wouldn't go over to their house and yell at them to get up and run a marathon, right? Well, many times that's exactly what we are expecting our bodies to do during infertility treatment. And if our bodies were good at this stuff, we wouldn't be in treatment in the first place. Even though you feel and look like the picture of health, you most likely have some medical condition or disease causing your problems. Keeping this in mind can help you move from a point of conflict to a point of empathy with your body.

3. Focus on what your body CAN do.

A few months after the "restaurant" incident, I went to the optometrist for my yearly checkup. I was surprised when, while examining my eyes,he told me that I had beautiful retinas and foveas. Apparently they were perfect, just like a teenager's. Learning from the last experience, I suppressed my urge to say that it was odd my eyes looked so young as I had the ovaries of a 50 year old. It was a small thing, but it made me feel a little better about my body. Okay, so good retinas and foveas may not be much, but seeing is important--my body wasn't failing me at everything. I started thinking about all the good things it could do--carry stuff, walk and hike, laugh, and eat ice cream. Remembering all the good things your body has done for you lately can help you come to terms with what it hasn't been able to do for you.

If you are finding yourself at odds with your physical sum or parts, remember, although this is an understandable response,it isn't conducive to long-term happiness. Developing some empathy for your body, and recognizing it's strengths, may help you resolve this issue for the long-term.

When your problems have problems--experiencing setbacks in infertility treatment

2010-09-02T14:32:00.000-07:00

Experiencing setbacks, disappointments, and other obstacles is very common when undergoing infertility treatment. In an emotionally charged environment, such occurrences can cause a great deal of distress. Many times I have seen clients, who are already upset about their situation, become very overwhelmed and anxious when a roadblock inevitably appears. Sometimes, their emotional responses have the potential to derail their treatment plans and chances for success, unless they can quickly recover and respond. As I myself have been no stranger to such bumps in the road, I have found it helpful to have a system of classifying the types of problems that can arise, because each type of problem requires a different type of emotional response and plan of action.

In my mind, I think the most important thing you can do when you get some bad news or a problem arises, is to stop, take a deep breath, and ask yourself, “What type of problem is this? Is it one that it is theoretically possible to fix-a “practical problem? Or is it one that has no practical or known solution?”

Practical Problems

These types of problems usually require solutions involving time, money, hard work, and patience. So if you think you have a practical problem, my advice is:

· Try to calm down
· Don’t get caught up in your feelings just yet (there’s time for that later); and
· Get to work on figuring out a solution, and then implementing it.

As a psychologist, you may find it odd that I’m advising you to put your upset feelings to the side for the moment. But it may be necessary to do that temporarily so that you have the mental and physical resources you need to get your process back on track. Then when things are settled, you can revisit and process these feelings.

An example of this type of setback occurred to a client of mine when her insurance company rejected her IVF claim for thousands of dollars, causing immediate (and understandable) panic! She immediately became quite overwhelmed and felt convinced she would no longer be able to afford her IVF treatment. After she was able to calm down, she could then see that this development, while unwelcome, wasn’t a deal-killer. Through many unpleasant phone calls and much determination, she was able to resolve the billing issues and continue with her treatment.

Another common example is when a treatment cycle gets delayed for a medical reason, such as an ovarian cyst, or other similar unavoidable factors. Usually, infertility treatment is so unpleasant, and people want a baby so much, that the idea of waiting even another month can be extraordinarily unsettling. However, in the long-term scheme of things, it probably isn’t going to be that big of a deal if Junior is born next March instead of next January.

My fundamental point here is that if your setback or problem can be fixed with money, time, or effort, than you are actually pretty lucky. When motivated, we are all capable of putting our full efforts into an endeavor; can all do; we can make time for the things that are most important to us; and if we put our minds to it, we can often even find creative solutions for accessing more money. It may not be fun or easy to fix these problems, but it is possible, and if we are motivated, we can do almost anything.

Problems you can’t solve

Notice that I said that we can do “almost” anything. Because there are other types of setbacks and problems that, no matter how much you may want to, you cannot control or fix. Sadly, this type of problem makes you long for a practical problem like the ones listed above. One common example involves being diagnosed with something that makes it impossible for you to achieve your current definition of successful treatment, such as finding out you have very diminished ovarian reserve, uterine problems, genetic and chromosomal issues, etc. For these types of problems, my suggestion is:

· Work through your feelings of anger and loss, and then;
· Figure out the “workaround”.

If you’ve just gotten some devastating news, and there isn’t anything that you can do to fix it, the most important thing you can do is to acknowledge to yourself that you are in a crisis, and start taking as good of care of yourself as you possibly can. Trying to put your feelings aside it this point is not helpful, and anyway, it is probably impossible. Talking to your partner, friends, family, or even a therapist will be beneficial and possibly necessary. If you don’t deal with these feelings, you probably won’t be able to make a good decision about what you are going to do next.

The workaround

If you’ve learned that you can’t achieve your goal, then you have two choices—either give up on your current goal, and select a new, entirely different one—or alter your definition of success. In the infertility treatment world, this may involve parenting children with whom you do not share a genetic relationship, whether through adoption or the use of donor gametes. The vast majority of those who go this route find that they feel very happy with their choice, and state they can’t imagine having any children other than their own. Of course, restarting the adoption or treatment process will inevitably bring up its own new set of problems— but hopefully “just” practical ones.

So if you are experiencing a setback, remember to stay calm, and try to think about what type of problem it is. If it is a practical problem, you will usually be able to fix it if you try. If it is a problem you can’t solve, you will first need to grieve the losses associated with this, and then decide on what alternative method you will use to build your family.

Relationship issues with your reproductive endocrinologist; the other kind of "transfer"

2010-08-26T12:22:00.000-07:00

One of the most important facets of infertility treatment is managing your relationship with your reproductive endocrinologist and fertility clinic. If you do not have open lines of communication and a certain level of trust in your doctor, your ability to make treatment decisions can become compromised.

While on the surface it may seem straightforward to develop and maintain your relationship with your doctor and his or her staff, in truth obstacles often develop. Many times, these stem from emotional issues and expectations on both the part of the patient and the part of the doctors and nurses. In this blog entry, I will describe some common emotional patterns that can impact the quality of the doctor/clinic/patient relationship from both the patient and clinician perspectives.

The patient side of the equation

In my opinion, one of Sigmund Freud's greatest contributions to the field of psychology was his development of the concept of transference. Transference occurs when we transfer our feelings and expectations about one emotional relationship (let's say our parents) to another relationship. Although Freud observed this within his therapist-patient relationships, in truth we all do this with many different types of relationships all day long. As children, we develop basic patterns of interactions, and expectations of how others are going to react to us. We then use this as a sort of emotional "shorthand" and apply it to other situations and relationships in our lives. As long as our early relationships with those important in our lives were reasonably healthy, this usually doesn't create any problems, especially if the relationships aren't emotionally intense. So transference, while it may be occurring, shouldn't pose any problems with your relationship with the person behind the counter at the drug store, or your dog groomer, etc.

However, infertility treatment is often an emotionally intense situation. The desire to have a child comes from some of our deepest and most central feelings, and these feeling often get stirred up by infertility treatment. So it is quite likely and understandable that infertility patients will at times experience strong emotional reactions to their doctor, nurses, or their clinic as a whole. A problem can occur when these reactions interfere with a patient's ability to listen to or communicate with their treatment providers. Let me give you some common examples I see in my practice.

1. Not wanting to challenge authority

Many times, I have observed clients who have been quite reluctant to ask questions or challenge their doctors on diagnoses or treatment decisions that didn't make sense to them. Despite feeling uncomfortable (and often, by the way, being correct in their own assessment of the situation) they were willing to go along with the doctor's opinion--until I started questioning them about their reasons for their passivity. Then it would often come out that they tended to have parents who were more authoritarian--and thus they were more likely to view others in emotionally important positions in their life as authority figures, rather than as peers or collaborators. Questioning someone they viewed as an authority figure was not something with which they felt comfortable. Although doctors have a great deal of knowledge and experience, they are still human, and thus not perfect. They may misunderstand things, miss some details, or just plain make mistakes at times. Without feeling like we can advocate for ourselves in medical situations, we put ourselves in danger of not getting the best possible treatment.

2. Not wanting to hurt the doctor's feelings

Many times, I have noticed that clients are resistant to getting a second opinion, even when it is obvious that their situation is very complicated and they are stuck in their current treatment situation. When asked, they often say they don't want to hurt their doctor's feelings by requesting their records and getting an appointment elsewhere. Often, these clients had families that placed a high value on loyalty, and they feel that being disloyal is one the worst things they can do. I personally think loyalty is a wonderful and essential part of human relationships, but it may be a bit misplaced in the context of a doctor/patient relationship. After all, reproductive endocrinology is a big business, and fertility clinics aren't treating clients just out of kindness and love--they want to make a profit. In addition, different reproductive endocrinologists have different strengths and areas of expertise, and thus fit is extremely important. Most physicians I have talked to about this issue are very open to and welcome the idea of a second opinion. So overvaluing loyalty in this context may prevent you from finding the best treatment providers and options for you.

3. Not wanting to listen to anybody

This relational pattern is on the opposite end of the spectrum of the first two, and perhaps the most dangerous of the three. Sometimes, if people have control issues with authority figures, they tend to take a rebellious stance with others, refusing to follow directions and advice even when it is in their own best interest to do so. This can spell disaster in infertility treatment. Although doctors may not be perfect, it is pretty likely that they still do know more than you do about this particular subject, and ignoring their recommendations on principle can make it very hard to proceed.

The doctor's side of the equation

In addition to describing transference, Freud also observed the phenomena of countertransference, which is simply the doctor's emotional reactions to the patient. Just like transference, countertransference occurs all the time, and most of the time, it doesn't cause any problems at all. At times, though, countertransference can create difficulties in the reproductive endocrinologist/patient relationship.

To see what I mean, I want you to think about what psychological factors might contribute to a person wanting to be a reproductive endocrinologist in the first place. In all of our career choices (and don't even get me started on the factors that might make someone want to become a psychologist!), our emotional issues or challenges are often a large part of why we are drawn to one career over another. So it stands to reason that your RE is no different from any of the rest of us. And getting lots and lots of people pregnant can't help but be an emotionally interesting experience. For example, I once had an RE who, whenever I was at the crossroads in making a treatment decision, would put his arm around me and say, "Lisa, if you were my wife, this is what I would tell you to do." Which was a little confusing and a little weird, frankly. How do you argue with that? After spending more time hanging around the clinic waiting for appointments, and talking to other patients, I soon realized that he was saying this to all of us--we were all his "wives". Once I overheard him comment to a nurse that his patients in the waiting room were different than those of the other RE's--they were friendly to each other, and fun to be around. Clearly, this was a man who liked his "wives".

I don't think it's a stretch to say that this doctor was getting some other psychological benefits out of his job other than the joy of helping others. And I think it probably impacted his ability to be objective about his patients and for them to be objective about him, which can't have helped their treatments.

This is just one type of example of how countertransference could cause problems for infertility treatment. As people are so unique, there are endless possibilities for transference and countertransference to occur.

So as you consider your own relationship with your doctor and clinic, think hard about what patterns and expectations you might be bringing to the table--as well as those that might be occurring with your treatment providers. By being more aware of these patterns, you can make the conscious choice to do something different--and that may make the difference between success and failure in infertility treatment.

Nasty little suprises--infertility and the iphone commerical

2010-08-19T12:13:00.000-07:00

Perhaps you’ve recently seen the commercial for the new iphone in which a woman tells her husband via the videoconferencing feature that she’s pregnant? I did, and I was surprised by the intensity of my own personal emotional reaction to it. I don’t think the commercial was even over before I ) felt overwhelmed with a profound sense of sadness and 2) found myself heading over to the freezer to dip into the emergency ice cream supplies.

The intensity of my reaction really took me off guard. Perhaps I flatter myself, but at this point in my life I consider myself rather hardened to these types of little reminders of my infertility. After all, it’s been over ten years since my entre into the infertility world, I now have children, and I think about and listen to other people’s experiences with infertility for a living. So if this advertisement got me upset, I can only imagine how someone who is currently in the thick of treatment, or who just got a negative pregnancy test, or had a miscarriage, would respond.

A quick google search of the words “iphone commercial infertility” confirmed this fear. Several women have posted on message boards, often with language I can’t repeat here, about having intense negative emotional responses to the commercial.

This started me thinking about how best to cope with little emotional “surprises” like the one I experienced with this commercial. When undergoing infertility treatment, we all know that there are certain situations that are most likely going to be upsetting—the often feared baby shower, for example, or the insensitive relative who can be counted on to say something upsetting. Usually we can emotionally prepare ourselves for such events, either by avoiding them if possible, or by somehow adjusting our expectations of ourselves and others. But what about those painful reminders that seem to come out of nowhere, seemingly unbidden, and catch us off guard?

To start with, I think we need to plan for the fact that these types of reminders will inevitably occur when struggling with infertility. The only real surprises are the timing and the content of the upsetting event. Thus, we need to be prepared to employ what I call “emergency coping strategies”, meaning the actions which can be relied on to calm us down quickly, if temporarily. Although I went running for ice cream in the above example, there are other, perhaps healthier strategies as well—talking to a friend, deep breathing, going for a walk, taking a relaxing bath, etc. It is always helpful to think about what things calm you down and make a mental list of them, so that you have them prepared in advance. When you are already upset, it can be very difficult to think of the best ways to cope. But if you have made a list in advance, you can quickly start implementing the appropriate and available strategies on your list when something upsetting occurs.

However, once we have dealt with the initial emotional crises, I also think that we need to learn to appreciate these painful moments, as they can give us insight as to how we really feel. For example, my response to the commercial, though unpleasant, was a signal to me that although in some ways I’ve moved on, I still have very deep feelings about my own experience with infertility that are important for me to understand. Understanding the specificities of your emotional reactions can tell you a lot about how you are really feeling. Talking to your partner, friend, family member, or a therapist may aid in this understanding. Not only will this provide some clarity, but it will also give you valuable information about yourself in order to make decisions about treatment and your future.

Does infertility change you as a person?

2010-08-19T11:46:00.000-07:00

Many times, my clients ask me if their experiences with infertility will change them forever. Usually, this “change” isn’t regarded in a positive light. I feel that change is inevitable. Over time, I feel that I myself changed on multiple levels as a result of my experiences with infertility, in ways both large and small. I have also observed similar gradual transformations this in my work with clients dealing with infertility. Although the thought of change can be unsettling, many of the changes I have observed in my clinical work are actually signs of increased personal growth and psychological maturity. To be honest, it may not be the most recommended or enjoyable way of achieving this growth--but as infertility is usually not a choice, we must take from it what we can.

To illustrate this, let me tell you a story about one of the smaller changes I noticed in myself as a result of my infertility adventures. A year or so after I stopped a two-year course of infertility treatment to pursue an adoption, for no particular conscious reason, I started thinking about progesterone in oil shots. As I mused about the painfulness of those shots, it suddenly occurred to me—they were progesterone in OIL shots. Meaning that, on and off for two years, I had been willfully injecting fat into my derriere, a part of my body that I had otherwise spent my entire adult life incessantly, albeit unsuccessfully, trying to make less fatty. What surprised me was not so much the idea that I had made that decision, but that I hadn’t even considered the oil/fat/derriere issue until a year later. During treatment, I focused so narrowly and single-mindedly on achieving a pregnancy that I had left my prior priorities, however shallow, behind without a second thought.

The above example, although seemingly trivial, demonstrates how experiencing infertility can produce profound shifts in our focus and our willingness to undertake hitherto unthinkable efforts. As we try harder and harder to achieve our goal of having a family, we often become more flexible and open-minded. Many times, when someone begins treatment, they have preconceived notions about what they will or will not do. I often hear people tell me that they would not ever consider IVF, using donor gametes, adoption, etc., at the onset of treatment only to later reconsider and find themselves actively pursuing the very possibilities they originally dismissed—and grateful for the chance to do so.

Such a change usually does not happen all at once—there seems to be a “just one more thing” quality to the process. As each type of treatment fails, the next round is just a little different. For example, going from clomid to clomid plus an IUI is just one more thing. Then it’s off to injectibles and IUI, and it that doesn’t work, IVF “just adds the retrieval and the transfer”, as my RE told me. If you made this shift all at once, you might be shocked by your future choices. However, as the process unfolds, a once unthinkable option may start to seem like the best choice after all.

In addition, as you go through treatment, you start to redefine your goals and distill what is really important to you. One example of when this type of perspective change occurs when it seems unlikely that a person will be able to have his or her own genetically-related children. Of course, this is a profound loss that must be mourned. From that loss, however, often comes a change in perspective about what exactly constitutes a family. Instead of the genetic relationship to the child, the quality of the interpersonal relationship becomes more important—people feel connected and related to their child because they devote themselves to caring for the child and share so many experiences together. Interpersonal relationships then become the defining feature of a family, not genetics.

This focus on the quality of interpersonal relationships can carry over into other types of relationships too, in that people are often better able to overlook surface differences and will be able to form deeper connections with a variety of people. Thus, they may develop a larger and emotionally closer network of social support. Their circle of friends may also become more diverse, allowing them to have access to new experiences and perspectives.

Another change I frequently observe is that people who have experienced infertility tend to have an increased capacity for empathy for others, regardless of the nature of their struggles. As I have mentioned in earlier posts, we tend to walk around with the myth that bad things only happen to other people. When something bad happens to you, this myth is shattered, forcing to you acknowledge that bad things really do happen. With that comes the realization of how profoundly painful such experiences can be, whether they happen to you or to someone else. Even though the nature of the hardship or disappointment may be different, you can still have a pretty good idea about how another person may be hurting. Also, almost everyone who has been in infertility treatment has experienced insensitive comments from others, and thus tries to be more thoughtful about what they say, or don’t say, to others.

Many of my clients have also reported that as a result of dealing with infertility, they have increased confidence in their coping skills. By surviving, and even triumphing over their struggles with infertility, they learn that they can survive difficult times, challenges, and disappointments. Plus, they have now developed more sophisticated coping skills, so that the next time a life crisis occurs, they are more prepared and can handle things more easily.

So let’s see here—increased open-mindedness and flexibility, increased capacity for connecting with others, increased empathy and sensitivity, and an increased sense of personal strength—those all sound pretty good, right? Now I know you may be rolling your eyes right now, and thinking that it isn’t worth it—the current pain of your situation is too great, and you’ve got enough character already! But since we usually don’t have a choice about the medical circumstances causing our infertility, all we can do is try to learn from our experiences as best we can. (For instance, my spending a lot of time futilely worrying about the size of my rump probably isn’t the most productive use of my energy, and it certainly isn’t making it any smaller!)

As long as we try to learn from our experiences, I think that the changes in that result from them will be mostly positive. In the case of infertility, the type of personal growth that occurs better prepares us to be parents—we have more emotional maturity and higher levels of tolerance for the stresses that lie ahead. There are several research studies that confirm this theory, in which parents who had experienced infertility prior to becoming parents scored higher on measures of effective parenting.

So if you are worried that your experiences with infertility are going to change you for the worse, remember that are most likely going to become an even more mature, emotionally sophisticated, and empathic person than you already are!

Common emotional pitfalls when choosing an infertility clinic or doctor

2010-08-19T11:43:00.000-07:00

Making good decisions about infertility treatment is crucial because the stakes involved are incredibly high. Having, or not having, a child is arguably one of the most life-changing decisions a person can make. In addition, infertility treatment is incredibly expensive—not just financially, but physically and psychologically as well. Being in infertility treatment (as you have probably already realized) can be quite physically uncomfortable and emotionally stressful. Most of us don’t have unlimited financial resources, and perhaps more importantly, none of us has unlimited physical and emotional energy to endlessly devote to treatment cycle after treatment cycle. So every cycle, every attempt must really count; every decision about what to do next is very important and must be treated as such. To make our very best decision in such a complicated situation, we must be functioning at our highest levels. If our emotions, as valid as they may be, are clouding our judgment, it can make it difficult to make the choices best for us.

In addition to having to make the best decisions for ourselves in the present, we also have to make sure we don’t look back at our current decisions years or decades from now and regret them. Infertility treatment, especially with your own eggs, has a time stamp on it, and we usually can’t go back years later and try again. So we must also think about what our future selves will feel about the decisions we make now. In my own case, I have done many rather difficult and unpleasant things so that 50-year-old Lisa won’t be upset, angry, and regretful (I sure hope she appreciates it!) I feel the regret factor is one of the most important decision-making variables we must include when making treatment decisions.

One of the most important infertility treatment decisions is choosing a reproductive endocrinologist or clinic. However, in my practice (as well as my own life experience) I have observed that this is one of the most common areas in which emotions may have a negative impact on the final decision. Too often, I see that the main criterion that people use to select an RE is that they want someone that really like and connect with emotionally. They want someone who is empathic and sympathetic, and who gives them a feeling of hope even if their diagnosis does not usually have a positive outcome. This is, of course, absolutely understandable. Usually, when we visit a RE, we are feeling sad, anxious, angry and scared, and finding someone that can understand, tolerate, and address these feelings feels good. However, (and I can’t stress this strongly enough) the purpose of your reproductive endocrinologist is not to make you feel better emotionally, but to provide you with the best information and treatment currently available. Thus, the main variables you should be looking for are how successful a particular RE or clinic is in treating your particular diagnostic, treatment, or age group category. Period. Anything else, like a nice relationship with that person, is a bonus.

Okay, so I know that seems like a pretty strong statement for a psychologist to make—that it shouldn’t matter if you like your RE or if you feel he or she cares about you. It’s a vastly different approach than I would suggest for choosing a therapist or an internist, because in those relationships you spend a lot of time with the person with whom you are working, and trust is a vital factor to successful treatment. But there are two reasons behind my thinking here. The first is that there is such variance between the number of cycles performed and the success rates of different treatment clinics. If you haven’t done it already, check out the success rates of the clinics in your area at http://www.sart.org/find_frm.html . You’ll see what I mean. In most cases, you are going to want to go a place that runs a lot of cycles and has good success rates. The RE’s who staff these clinics may, or may not be the type of person you’d love to hang out with, or wish lived next door. But again, that’s not really the issue--getting the best treatment possible, so you don’t waste your time, tears, and money, and don’t have regrets later, is the most important issue at hand.

The second reason I feel that it doesn’t matter too much if you don’t have a warm and fuzzy relationship with your RE is that you probably aren’t going to be spending a lot of time with them anyway. In most cases, you are going to have a lot more contact with the nurses, technicians and other staff, and often, these clinicians are more overtly empathic and understanding.

I should add that I think that getting emotional support about your infertility from someone who understands what you are going through is extremely important. But that support can come from a variety of other sources, like family, friends, support groups, and clinicians specializing in infertility like myself. In my opinion, it is unrealistic to also expect it from your RE, who should be focusing on the medical and scientific aspects of your case.

Another common problem I see is that sometimes people want to make the decision about treatment providers based on other variables like geographic proximity, because they want to lessen the “inconvenience” of infertility treatment. While nobody likes to have to commute out of their way morning after morning to go to monitoring appointments, or even cycle at a clinic in a different town, sometimes it may be a short-term but necessary evil in order to ensure that you are getting the best treatment and the best chances for having the family you desire. I once talked to a friend who was having difficulty getting pregnant. She was quite distressed that she had two failed IVF cycles at Clinic X, which had very poor success rates and did not do many cycles. When I suggest she move her treatment to Clinic Y, which had much higher success rates for her age group, she was very resistant initially because Clinic X was close to her house. Clinic Y was not, and she didn’t have a car, so she would have to take a taxi to her retrieval and transfer. I think she was a bit shocked by blunt question about what was more inconvenient to her—taking a few taxi rides, or not having a baby at all. But she did take my advice and switch clinics, and now a few babies later, I think she’s glad she did.

I think one of the reasons such seemingly irrational decisions occur is that people may not want to acknowledge the far-reaching impact of infertility on their lives. Somehow, commuting across town or even across the country for infertility treatment makes it seem all the more real and painful. The unfortunate truth, however, is that infertility affects us deeply, whether we consciously acknowledge it or not. And the consequences of our decisions are profoundly life-altering events which, one way or another, will shape the future course of our lives.

So if you find yourself unsure of what to do when choosing a treatment provider, make sure to take the time to try to really understand what you are feeling. Remember that picking your treatment provider is an incredibly important decision with far-reaching consequences, and that you definitely want to try to avoid having long-term regrets later in life. In order to give yourself the best chance of success, you may have to make choices that don’t “feel good” in the short term.

Although you may not be able to use your feelings as the sole basis of your decision, they are still very important to understand and process. It may be helpful to talk to someone else in order to clarify these feelings, such as your partner, a family member, a friend, or a mental health professional. By being more conscious of what your feelings are and how best to respond to them, you will be freer to make the best choices for you in the long run.

Infertility, self blame, and the fiction of doom; why it is probably not your fault

2010-08-19T11:40:00.001-07:00

As a clinical psychologist who specializes in working with infertility issues, one of the things I’ve learned is that every person’s story and situation is truly unique. Infertility is one of those life experiences that usually pushes a lot of emotional buttons. Everyone has different buttons, and thus responds differently.

But there is one thing I’ve heard from almost everyone facing infertility at some point in their journey (including myself), and it’s some version of this---that infertility is somehow God’s/the universe’s/karma’s (insert spiritual force of your choice here)’s little way of telling you that you shouldn’t be a parent because you are somehow, or were somehow, bad.

Everyone has their own personal spin on this story, too, when it comes to the details of their alleged horribleness. Often, people seem to struggle to come up with an actually plausible reason for their punishment, because the truth is that they haven’t ever even come close to doing something that would deserve that kind of response. What would, really? Some of the explanations, if the whole situation wasn’t so sad, would actually be pretty funny. Also, almost everyone is able to acknowledge that this is irrational and that all manner of people with glaringly obvious challenges to their parenting skills are able to procreate freely.

But they all still believe that it’s somehow their fault anyway.

Did I mention I myself am not immune to this sort of magical thinking? I remember telling my first RE on more than one occasion that my infertility was a punishment for something I had done in a former life. I also remember being pretty shocked when one day he agreed with me, saying, “I don’t know what you did in that former life, but it must have been really, really bad!”. Not the treatment prognosis you really want to hear, but more on that whole situation another time.

So why do we do this? Why do we torment ourselves even though we rationally know it isn’t, can’t be, our fault?

My theory is that it is our attempt to create meaning and order in a painful, chaotic experience. That somehow it seems more painful to realize that most infertility is probably the product of some random chemical and/or cellular mishaps over which we have no control, because then we must admit that we have, at best, very limited control of the outcome.

This phenomenon is not exclusive to dealing with infertility, however. People often have a very hard time admitting they don’t have complete, or sometimes even partial control over their bodies and their destinies. This purpose of type of defense is to help us function in everyday life. We all walk around every day with all sorts of fictions and denials designed to prevent our realizing, say, that at any second, there is a small but possible chance that we, or a loved one, could be in a car accident, be diagnosed with serious illness, a victim of violent crime, etc. The possibilities for peril are endless even if they are, thankfully, unlikely. But if we constantly hold these possibilities in the forefront of our minds, we would be paralyzed by fear and we wouldn’t be able to function. One way of coping is to create fictional beliefs about our control, such as “I won’t be in a car accident because I’m a good driver.” Although this may not actually be true—being a good driver may reduce one’s chances of being in a car accident, but as accidents can be caused by other drivers’ mistakes, it does not eliminate the risk—it allows us to get behind the wheel and drive to our next destination.

When it comes to situations like infertility, this coping mechanism starts to work against us. Because we have limited conscious control over the inner workings of our bodies when things go awry, we are forced to “go negative” to create a fictional belief that allows us to have the fantasy of being in control. This is where thoughts like “I must be a bad person”, and “I do not deserve to be a parent” come into play. Since we can’t control it physically, it pushes the explanation into the karmic, moral and spiritual realms.

The good news, though, is that once we realize that these negative beliefs about ourselves are not true, but just a misguided way to feel like we are more in control of the situation, we can start to let ourselves off the hook. And being fully aware of the truth of the situation—that we (or our doctors) ultimately have limited control over what our hormones, organs, and cells will do—allows us to take a different perspective on ourselves and our treatment. Once we can get our self-esteem and cosmic self-worth out of the equation, we can make better treatment and life decisions for ourselves. It is so much easier to decide what is best for you, your family, and your future if your worth as a person is not tied into it somehow.

So you if you are reading this, and you’ve been blaming yourself on some level for your infertility, please know that it is very common, and that you are certainly not alone. Try taking a more skeptical view on your own ideas about what you’ve done wrong, or why you think this might be happening to you. Most likely, you will realize that these thoughts and beliefs aren’t so much about your current situation, but instead stem from your wish to have more control over the situation than is possible. It is important to remind yourself, often repeatedly, that your worth as a person and your ability to reproduce are almost always completely separate things. In so doing, you may be able to free yourself from feeling bad about yourself and doomed in your situation, and develop a fresh perspective to help you succeed with the challenges that come your way.