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, August 26, 2010

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

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

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

The patient side of the equation

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

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

1. Not wanting to challenge authority

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

2. Not wanting to hurt the doctor's feelings

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

3. Not wanting to listen to anybody

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

The doctor's side of the equation

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

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

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

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

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

Thursday, August 19, 2010

Nasty little suprises--infertility and the iphone commerical

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

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

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

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

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

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

Does infertility change you as a person?

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

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

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

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

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

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

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

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

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

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

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

Common emotional pitfalls when choosing an infertility clinic or doctor

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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