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!

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.

Thursday, September 9, 2010

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

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

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

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

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

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

1. Acknowledge your feelings

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

2. Try to develop empathy with your body

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

3. Focus on what your body CAN do.

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

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

Thursday, September 2, 2010

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

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

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

Practical Problems

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

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

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

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

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

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

Problems you can’t solve

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

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

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

The workaround

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

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