This blog addresses various emotional aspects of experiencing infertility. It is written by a clinical psychologist who specializes in infertility counseling. Thank you for reading, and best of luck with your journey!

Thursday, December 30, 2010

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

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.

Monday, December 20, 2010

Infertility and the holidays: Misery loves company?

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.

Thursday, December 16, 2010

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

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!

Thursday, December 9, 2010

Resilience is the real fertility

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.

Thursday, December 2, 2010

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

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.

Saturday, November 20, 2010

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

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!

Tuesday, November 16, 2010

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

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.


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.


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.

Tuesday, November 9, 2010

Couples issues in infertility treatment: some thoughts

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!

Wednesday, November 3, 2010

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

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.


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.

Wednesday, October 27, 2010

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

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.

Wednesday, October 20, 2010

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

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.

Wednesday, October 13, 2010

Infertility treatment, love and courage

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.


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.


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.

Saturday, October 9, 2010

Infertility and competitiveness among women--a question

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!

Thursday, October 7, 2010

Ambivalence--its role in decision making in infertiity treatment

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.


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.

Wednesday, September 29, 2010

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

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.

Thursday, September 23, 2010

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

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.

Thursday, September 16, 2010

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

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.